Health Aide Procedure Manual - San Bernardino City Schools

Transcription

SAN BERNARDINO CITY UNIFIED SCHOOL DISTRICT
HEALTH SERVICES
HEALTH AIDE
PROCEDURE
MANUAL
Revised
October 2012
SAN BERNARDINO
CITY UNIFIED SCHOOL DISTRICT
SUPERINTENDENT
Dale Marsden, Ed. D.
BOARD OF EDUCATION
BARBARA FLORES – BOARD PRESIDENT
MIKE GALLO – VICE BOARD PRESIDENT
DANNY TILLMAN
MARGARET HILL
JUDI PENMAN
SHARON PERONG
LYNDA SAVAGE
ADMINISTRATIVE OFFICERS
HAROLD VOLLKOMMER, Ed.D.
ASSISTANT SUPERINTENDENT
JOHN PEUKERT
KENNON MITCHELL, Ph.D.
ELISEO DAVALOS, Ph.D.
TABLE OF CONTENTS
HEALTH AIDE- Job Description
Substitute Health Aide info sheet
Can / can’t do list
Daily activities / Daily Medical Log
Home visits / Mileage
Opening & Closing of School
ACCIDENTS / INJURIES, EMERGENCIES & ILLNESS
Accident Reports
Student / Visitor Injury Report form
Definitions for Injury Reports
Emergencies
Emergency Procedures
When to call 911 / Paramedics
Signs of Concussion
Emergency Information Card
Blood and Body Fluid Precautions
Biohazard Waste sign
Student post exposure evaluation follow-up
Illness
Common complaints-recommended action
First Aid Follow up instructions-forms
Communicable Diseases
Communicable disease information sheets
Handwashing Flyer
First Aid Supplies
First Aid Field Kits
First Aid Kits for classroom
Religious Exemption
CHILD ABUSE RESPONSIBILTIES
Child Protective Services Reporting school guidelines
Suspected Child Abuse Report form
DENTAL
Dental Screening- dental notice form
Oral Health Assessment / Waiver Request Form
Oral Health Assessment Site Totals form
DIABETES
Diabetes Management Orders
Blood Sugar and Insulin Calculation Worksheets
Glucagon
Hypo/Hyperglycemia symptom flyers
TABLE OF CONTENTS cont.
FIRST GRADE PHYSICALS
First Grade Physical letters to parents
First Grade Physical Exclusion Letter
List of Clinics
Report of Health Exam
Waiver of Health Exam
IMMUNIZATONS
Immunization Requirement For School Admission - Policy No. 2331.ab
Guide to immunization requirements for school entry
Check list for Evaluating Immunization Records
Immunization Interval Reference Sheet
Exemption Information
Tdap waiver form
Notice of Inadequate Immunizations
Immunization flyer
LICE
Head Lice Alert – Information sheets for parents
Head Lice information sheets school
ADMINISTERING MEDICATIONS
Medications at School- District Policy
The FIVE Rights
Letter to Parent/Guardian
Medical Abbreviations
Medication Record Card (example)
Physician Recommendation for Medication (example)
Physician Recommendation for Medication form
Emergency Medications Flyers to Post
REFERRALS
Child Welfare Fund
Child Welfare Referral
Sociological Services
Referral for services form
Operation School Bell
Assistance League referral forms
SCREENINGS
Hearing
Scoliosis
Vision
OTHER INFORMATION
School Nurse
Special Schools and Programs
PERSONNEL COMMISSION
HEALTH AIDE
DEFINITION
To provide support to the School Nurse by performing certain direct health services; and to perform a wide
variety of clerical duties.
SUPERVISION RECEIVED AND EXERCISED
Receives general supervision from a Principal or the Health Services Coordinator. Technical and functional
supervision is provided by a School Nurse.
Exercises no supervision.
EXAMPLES OF DUTIES - Duties may include, but are not limited to, the following:
Administers first aid in accordance with school policy. Maintains health office supplies and equipment. Stocks
and distributes first aid supplies to designated areas. Maintains the health office environment, including bulletin
board displays and exhibits. Provides transportation to parents and children as needed in school related
emergency situations. Makes home calls on health related matters as directed by the School Nurse. Makes
appointments for the school nurse with students, parents, teachers and community agency personnel. Assists
with appraisal activities by scheduling appointments, preparing equipment and records, and facilitating traffic
flow. Records standardized information on students' cumulative health records. Types, duplicates, collates and
distributes health instructional material as directed by the School Nurse. Orders audiovisual and other materials
from various sources. Acts as health office librarian. Prepares and maintains a variety of reports and records as
assigned. Performs clerical duties as assigned. Performs related duties as assigned.
QUALIFICATIONS
Knowledge of:
Basic principles and practices of first aid and CPR.
Modern office practices, procedures, methods and equipment.
English usage, spelling, grammar and punctuation.
Principles and procedures of basic record keeping.
Ability to:
Provide first aid to children.
Respond calmly and effectively to emergency situations.
Understand and follow oral and written directions.
Respect the confidentiality of health records.
Maintain simple records.
Work effectively in the absence of supervision.
Health Aide
Communicate effectively, both orally and in writing.
Establish and maintain cooperative working relationships with those contacted in the course of work.
Operate a typewriter.
Provide automobile transportation and make home visits.
Experience and Education/Training (These are the minimum experience and education/training standards which
will be used to admit or reject applicants for examination as approved on August 27, 1996.)
Some experience working with children in a health services environment is desirable.
High school graduation or the equivalent. Additional college level course work in child growth and
development or a related field is desirable.
Licenses/Certificates/Registrations
A current American Red Cross First Aid Certificate or an acceptable equivalent.
A current American Red Cross CPR certificate which includes infants, children and adults or an acceptable
equivalent.
An appropriate, valid California driver's license and proof of insurance.*
SPECIAL REQUIREMENT
Personal automobile for performing duties required of the position.**
*Must be presented/**available upon offer of employment and maintained throughout employment in this
classification.
Rev. 2-97
SUBSTITUTE HEALTH AIDE GUIDE
THANK YOU FOR YOUR HELP TODAY!
PLEASE READ ALL INSTRUCTIONS REGARDING HEALTH OFFICE PROCEDURES
MEDICATIONS:
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All students must be called out of class if they are on med. schedule and forget.
All medication administered MUST have a Physician’s Medication Order form on file.
Read the label on the bottle 3 times comparing it with the student’s name.
Check the proper amount to administer (label may not be accurate because the doctor has changed the dose, the
correct amount will be on the Medication Record).
Document all medication given to each student on the medication record.
If a parent brings in medication, count number of pills and document on medication record.
REMEMBER: DO NOT GIVE ANY MEDICATION TO A STUDENT WHO DOES NOT HAVE A PHYSICIAN AND PARENT
SIGNED ORDER FORM, OR FROM A PRESCRIPTION BOTTLE THAT IS NOT LABELED
FIRST AID:


Always wear gloves when handling blood or body fluids
Follow first aid procedureso Clean wounds with soap and water, apply band aid
o Apply pressure to bleeding wounds
o Do not move students who may have a suspected back or neck
o If a student has a possible fracture, do not move the limb
Notify Parents ,Site Administrator and School Nurse for all injuries.
Fill out a First Aide Follow- Up Form
CALL 911 for serious injuries or accidents that need immediate treatment.
DOCUMENT ALL HEALTH OFFICE VISITS in AERIES or a health log
STUDENTS WITH HEALTH CONCERNS:
DIABETES - Be sure you have been trained to assist a student with Diabetes. If not, please notify the school
nurse immediately.
Review all diabetic orders/procedures, familiarize yourself with the students. Always respond to diabetic student
quickly. Review the physician’s orders to know how to help a student with blood sugar testing and treatment for
low or high blood sugars. Treat as ordered and contact the school nurse.
SEIZURES – If student has a seizure (and has a known seizure disorder) - move objects away from student and
lower student to the ground, do not put anything in mouth. Allow to rest and notify parents.
Call 911- if student has never had seizure before, or seizure lasts more than 5 minutes, or has one seizure after
another.
Do not give the student anything to eat or drink until fully alert.
ASTHMA- Administer medication/inhaler as ordered, sit student upright, be calm, encourage student to breathe
slowly and deeply. Give room temperature water to drink. If symptoms not relieved, call parents.
Call 911- If symptoms get worst (loud wheezing, persistent cough, difficulty speaking in full sentences, loss of
consciousness, lips and nails turning blue).
IF YOU HAVE ANY QUESTIONS OR CONCERNS, PLEASE CONTACT THE SCHOOL NURSE OR
HEALTH SERVICES
HEALTH AIDES/CLERKS GUIDELINES
CAN
Periodic head lice screenings and follow up on excluded students.
Administer minor first aid for students and staff. Take care of external bruises, cuts and
compress, and take care of dirty pants, and clothing problems.
scrapes. Apply cold
Review cums for blue immunization cards, check for adequate immunizations, and check for 1 st grade or CHDP
physicals.
Generate exclusion letters for immunizations, 1st grade physicals and head lice. Provide families with a list of
resources.
Readmit students back to school for any of the above.
Assist nurse with mandated screenings.
Chart mandated screening date and results of vision, hearing and scoliosis in AERIES.
Weigh and measure students.
Give and chart prescribed medications, if trained by attending the yearly medication inservice, or trained by
school nurse. Count number of pills for medications as needed and document on the medication record.
Assist with diabetic testing using Universal Precautions.
Do special procedures such as diabetic monitoring, emergency medications, nebulizers and toileting as trained by
school nurse.
Order supplies for Health Office.
Call nurse for any serious injury.
Make nurse aware of any new health problems.
Fill out accident and CPS reports as needed.
Send home a first aid follow up and/or call the parent.
Document in AERIES or other logs as deemed necessary by nurse.
.
Work under guidelines of Health Aide Manual and Emergency First Aid Guidelines for California Schools.
Home visits on follow ups as appropriate.
HEALTH AIDES/CLERKS GUIDELINES
CANNOT
Diagnose.
Evaluate students after a hospitalization and / or long absence.
Splint or ace wrap without consulting with school nurse.
Apply butterfly or steri-strips bandage.
Remove a foreign body.
Give injections - unless for emergency situations such as anaphylaxis or diabetic emergency. (To give Epi-pen
and glucagon injections, you will need to be trained by the school nurse or attend the annual medication inservice.)
Do mandated vision or hearing screening.
Counsel.
Make a referral for students/parents to an outside agency such as SAC, CHDC, Behavioral Health Clinics.
Call doctors or their office except to clarify immunizations or unreadable orders.
Attend IEP meetings in place of the school nurse.
Set up special health protocols.
Do health and developmental assessments.
Do health teaching.
Act as a medical liaison between district, doctor, and/or parent.
(May act as a translator for Spanish speaking families.)
Allow themselves to be identified as the nurse.
DAILY ACTIVITIES
1. Record in AERIES all student contacts, parent conferences, transporting, or other significant activities throughout
the day.
2. Confidentiality of records must be maintained.
3. Evaluate acute illness or injury, do first aid, and report to parent or school nurse as necessary
4. Keep complete and current EMERGENCY INFORMATION CARDS on all students
5. Maintain First Aid supplies for office, classrooms, and field kits.
6. Screen students as needed for infestations such as head lice
7. Assist in evaluation of immunization for admission and initiate follow-up
8. Assist in administration of medication and required record keeping
9. Transport children who are sick, have minor injuries or who have essential medical appointments when no other
transportation is available
10. Restrict use of Health Office restrooms to students who must remain in the office a period of time, or who have
special problems. Monitor restrooms for proper use and sanitation.
11. Maintain a neat, attractive, well organized and educational Health Office. Desks and cabinets should be kept
clean and stocked. (Posters and health information should be current)
12. Determine needs of students as soon as possible. Arrange for dismissal rapidly for students who cannot stay in
school, return others to class promptly, keep cot use to a minimum, discourage loitering
13. Follow-up on dental or health problems as directed by school nurse
14. Make home visits as necessary
15. Keep record of business mileage
DAILY MEDICAL LOG
The Daily Medical Log in Aeries is used to keep an up-to-date record of student, parent, and other
important contacts, as well as to provide data regarding the use of the Health Aide’s time.
Daily Medical Log
Date
Current Initials Hide Names Update Page
08/01/2012
Student Code
Update Page
Start
Time
End
Time
Start
Date
End
Date
Result Tag
Add New Record
The Health Aide should:
1. Make entries as soon as possible. Develop a habit of recording information as soon as
the contact is made
2. Enter name, complaint, and action taken
3. Record all home visits, transporting, and other school business
4. Keep log as brief but complete as possible. Questions often arise days, weeks, or
months later-your documentation may be essential to prove action was taken
HOME VISITS
Home visits may be very useful when:
There is no phone
There is significant importance in the parent contact
Information about the home situation is needed
Caution: Do not go alone into a home that appears to present any threat. If you feel it is unsafe
when someone answers the door, tell them you would like to make an appointment to meet with
them at the school.
Refer to principal or school nurse, or take other school personnel with you. The person to whom
you are referring the case should always be informed of your concerns.
MILEAGE
A record should be kept of all school-related mileage to assure proper reimbursement
Check mileage when leaving school (or first location of the day) and again on return to school
Record purpose of the trip
Submit completed mileage voucher form at the end of each month
Example of form
Form: Automobile Mileage Voucher SU-38
Obtain forms at your school site
OPENING OF SCHOOL
1. Clean and stock First Aid cabinets.
2. Supply and distribute First Aid Kits to classrooms.
3. Check and restock First Aid Field Kits.
4. Stock desk and/or files with adequate supply of forms and routine office supplies.
5. Work with office staff to obtain new Emergency Information Cards.
6. Review Emergency Information Cards to determine immediate needs and priority cases.
Notify school nurse of results.
7. Begin screening for head lice (this can be done as students come back on track).
8. Review immunization records for compliance and update any new information in Aeries.
9. Check files for Immunization compliance.
10. Check files for first grade physicals compliance.
Many of these activities need to be repeated throughout the school year to accommodate track changes and
mobility of students
CLOSE OF SCHOOL
The San Bernardino City Unified School District school year is from
July 1 to June 30, regardless of the various schedules at different schools.
This is important because many forms or requests expire at the end of each school year
ALL SCHOOLS:
1. Start preparation for Close of School in late April or early May.
2. Consult with your school nurse about students who have special orders that will
expire and how to send forms to parents for the next school year:
a. Medication orders
b. SPHC’s (Specialized Physical Health Care orders), for blood glucose testing,
nebulizers, etc.
c. Students with long term P.E. excuses or exemptions
d. Students on Home Teaching
e. Students with special transportation for health reasons
3. Review and work with school nurse on uncorrected dental or vision problems.
4. Plan to store or file all notes, logs, etc. that should not be destroyed.
5. Check with your school nurse about disposal of any medications and sharp
containers
TRADITIONAL AND D TRACK SCHOOLS: add the following
1. Notify parents that they must pick up medications and
equipment on the last school day. It will not be stored over the summer months.
2. Check and order office and First Aid supplies for the beginning of the new school
year.
3. Notify teachers of plan to collect, clean and restock First Aid kits on the last day of
school.
4. Clean out desk and cupboards.
5. Take down and store health education materials.
6. Store valuables in a safe place.
INJURIES, ILLNESS, ACCIDENTS, and EMERGENCIES
Accidents, injuries and illness must be handled with great care to protect the child, the school and yourself.
GIVE FIRST AIDE ONLY
Do not TREAT Do not DIAGNOSE
A medical emergency is generally defined as a life-threatening situation in which immediate interventions are
needed to preserve life. These are rare occurrences (i.e., unconscious and/or not breathing, possible head, back,
neck injuries, fractures where the bone is sticking through the skin). Scalp lacerations, broken arms, or not
being able to notify parent, does not, constitute an emergency. Doctors will not treat a child without parental
permission unless treatment is needed to save his/her life.
SCHOOL INJURIES
1. Provide First Aid according to standard First Aid procedures and EMERGENCY FIRST AID
GUIDELINES FOR CALIFORNIA SCHOOLS.
2. Evaluate how, when, and where the injury occurred. Get names of people involved, or who witnessed the
incident.
3. Notify school administrator if incident is of any possible significance.
4. Notify parent, guardian, or emergency contact, they assume responsibility for care.
5. Call Paramedics if necessary, contact your School Nurse.
6. Transport minor injuries, if necessary.
7. Fill out an ACCIDENT REPORT form if indicated.
8. Follow-up with a parent contact the next day if the incident was of any significance, if the child is out of
school, or if Public Relations are important.
9. For minor injuries, when you cannot reach a parent by phone, use FIRST AID FOLLOW UP
INSTRUCTIONS.
NON-SCHOOL INJURIES
1.
2.
3.
4.
Evaluate need for medical care or home visit.
Notify parents, or transport if necessary.
Help parent obtain necessary care.
Use common sense to help keep child in school.
STUDENT/VISITOR ACCIDENT REPORT
This may be completed by any responsible employee who witnessed the injury or assisted with the first aid.
Complete the STUDENT/VISITOR INJURY REPORT for all incidents of:
1. Injury of any significance
2. Injury resulting from confrontation between two more persons.
3. Any questionable incident that should be reported and documented.
Be as specific and clear as possible. Please see “DEFINITIONS FOR INJURY REPORTS”.
You may complete the form, scan and email completed copies or send completed forms via pony mail to
the Environmental Safety Office.
DO NOT RELEASE THIS REPORT TO ANYONE
Form:
Number:
Student/Visitor Injury Report
RM-2 (Rev 01/10)
See next page for form--------- duplicate as needed or obtain form from your school site
DEFINITIONS FOR INJURY REPORTS
INJURY
DEFINITION
Abrasion
A wound that resulted from scraping or scratching
Amputation
Traumatic removal of body part
Bite
Wound made by teeth, pincers, snakes and insects
Bruise
Injury from blunt object that does result in scraping, bleeding, or
Puncturing (should be measured in inches or cm’s)
Dislocation
Any two or more bones out of alignment with each other
Fracture
Break or crack of bone
Laceration
Tearing of skin
Poisoning
Ingestion of toxic food, chemical, or drug
Puncture
Object penetrates the skin or deeper
Scalds
Heat injury from hot liquid or steam
Scratches
Scraping of skin by sharp object
Shock
Condition of systemic imbalance that may follow trauma of any kind, resulting in loss of
consciousness, pallor, low blood pressure, or cold, clammy skin
Sprain
Joint injury resulting from being forced beyond normal limits or range of motion
Emergency Procedures
Students, staff members, or visitors that incur injuries while on the campus or experience life
threatening symptoms from a health condition should receive emergency first aid from a
qualified staff member immediately.
For injuries that may require more extensive assessment and treatment, the paramedics should
be called. The paramedics can also contact an ambulance to transport the person to the hospital
if the injury or illness is life threatening or follow-up care is required immediately.
You may also need to contact your school nurse, Health Services, Environmental Safety or
Superintendent’s office, but should not delay care to the injured or ill person. Our school nurses
are available to assess the person but do not have the emergency equipment available that may
be needed to provide treatment. You should also contact the parent or guardian. Remember, you
should always call 911/Paramedics first for the following types of injuries or illness:
Injury, Illness or Condition
Some Possible Causes
Head Trauma
Fall, sports activity, fight, vehicle accident;
(Possible loss of consciousness)
Breathing Difficulty
Compound Bone Fractures
Asthma, anaphylactic reaction, drug
overdose, chest trauma;
Fall, sports activity, fight, vehicle accident;
(Note: Bone may be exposed)
Chest Pain
Heart attack, angina, chest trauma;
(Non-Asthma Related)
Prolonged Seizure
(>5 minutes)
Spinal Injury
Diabetic Coma
Seizure disorder, insulin reaction, head
injury;
Fall, sports activity, vehicle accident;
Insulin reaction, low or high blood sugar,
 Reference your “Emergency First Aid Guidelines for California Schools” notebook for more
information
 Complete a “First Aid Follow-Up Instructions” form and “Student/Visitor Injury Report” (RM-2).
The Student/Visitor Injury Report is for internal use only.
EMERGENCY INFORMATION CARD
An EMERGENCY INFORMATION CARD should be obtained and kept current for each student.
Use:
1. To contact parent or other authorized person
2. To obtain emergency care by designated physician or County Hospital
3. When parent cannot be contacted, have responsible person take card with the student as proof of
parental permission for care.
NOTE: Most hospitals and clinics will not treat a student without a parent or guardian unless the
problem is life threatening.
Form:
STUDENT EMERGENCY DATA
Number: BU-5
BLOOD AND BODY FLUID PRECAUTIONS
Purpose: To prevent infection or cross contamination from patient blood, body fluids or tissue.
Procedure:
1. Wear gloves whenever your hands are likely to come in contact with human
blood, body fluids (i.e., urine, saliva, feces, semen, vaginal discharge) or
open wounds.
2. If you have long nails or jewelry with sharp edges, rubber gloves are very likely to rip when putting
them on. It is essential to remove excess jewelry or consider minimizing your hand accessories.
Long nails and jewelry also trap and hold bacteria making hand washing less effective.
3. Thorough hand washing is the most effective means of preventing the
spread of disease. Gloving does not replace it.
4. A red biohazard sharp container should be in the Health Office for proper
disposal of sharp, blood stained objects. When this container is full, secure the cover on it and
contact your school nurse regarding disposal.
5. Waste baskets in the Health Office should be double-lined with plastic bags.
6. A plastic-lined container with a lid should be placed in the Health Office
bathroom for disposal of blood stained items.
7. A Biohazard sign must be posted in the Health Office.
STUDENT POST EXPOSURE EVALUATION AND FOLLOW-UP
When a student is involved in an exposure incident, it should be reported to the School Nurse or
Health Aide, principal or designee and Risk Management office
Complete an accident/incident report
A First Aid Follow-up Instruction form should be given to the student as a method to refer them to their health
care provider for post-exposure evaluation and follow-up.
The follow-up should include:
Documentation of the route of exposure and the circumstances related to the incident
If possible, the identification of the source.
Contact Risk Management for further instructions.
Post exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health
Service.
Counseling concerning precautions to take during the period after exposure incident and the potential
illnesses that may result.
ILLNESS
Students visit the health room with a variety of complaints
It is always necessary to investigate all problems in a systematic order
Questions to ask
Pain and location?
Quality- How bad is the pain?
Treatment- Are parents aware, what have they done, has a doctor been consulted?
Symptoms- Any other complaints?
Time- When does the problem occur, what were you doing?
Any history of health problems?
Remember
Do not diagnose or treat beyond first aid measures
Notify parents
Notify school nurse when appropriate
WHAT IS A FEVER? - TAKING A TEMPERATURE
“FEVER” is simply a higher than normal temperature
Normal oral (by mouth) temperature is 97-99 degrees
Most fevers are caused by infection. The most common infections in school-age children are tonsillitis, sore throats, ear
infections and bronchitis.
The child may be sent home from school if the temperature is more than 100.5 degrees, but there are other factors to
consider. A sick child may not register an elevated temperature when you take it.
Taking a temperature:
If taking the temperature by mouth, the child should not have hot or cold liquids within ½ hour before taking a temperature.
The child should not have been exposed to extreme weather changes (i.e., from warm classroom to cold outdoors to warm
office)
Use the digital thermometer, ear thermometer or temp strips according to directions on package. Ask for help if you are not
sure of the equipment.
COMMON COMPLAINTS
AND
RECOMMENDED HEALTH AIDE ACTION
COMPLAINTS
RECOMMENDED HEALTH ACTION
Allergies: runny nose,
Itching eyes, sneezing
1. Have child wash hands and then rinse affected area with
cool water.
2. Notify parent if necessary
Asthma
1. Encourage upright/sitting position
2. Use prescribed medication
3. Encourage drinking room temperature water
(not iced drinks or hot)
4. If no relief after 5-10 minutes, or if symptoms re-occur,
notify parents
5. Return to class when breathing and color is normal
6. Call parents/paramedics if: lips or nail beds are blue,
change in level of consciousness-confusion
Cuts, blisters, etc
See First Aid for Injuries and Sudden Illness
Headache
1. Check temperature
2. Ask about eating and sleeping
3. If no fever or other complaints, may return to class
4. Notify parents if necessary
5. Notify school nurse if this is a common complaint
Minor bruises
1. Cold pack
2. Return to class
Sore throat
1. Check temperature
2. Notify parent if:
Temperature above 100.5
If swallowing is difficult or painful
Swelling or limited
movement of a joint
1.
2.
3.
4.
Four steps to save a
Knocked-out Tooth
1. Rinse tooth in cool water, do not scrub
2. If possible replace tooth back into socket and hold in
place
3 If this cannot be done, wrap it in a wet cloth and drop it in a glass of milk
Cold pack/ice
Rest
Notify school nurse
Notify parent
4. See a dentist IMMEDIATELY.
FIRST AID FOLLOW UP INSTRUCTIONS
Minor illness and injuries should be reported to parents in writing when a personal contact is impossible or not
indicated.
The Health Aide should complete a FIRST AIDE FOLLOW UP INSTRUCTION form, make a copy of the form to keep
on file, and send the original home with the student
Example of form:
HEALTH SERVICES DEPARTMENT
FIRST AID FOLLOWUP INSTRUCTIONS
Dear Parent:
Your child,
was given first aid at________________
today,
a.m./p.m.
, for ____________________________________________.
Followup care by your family doctor may be important. Please follow carefully the instructions checked below:

Head Injury
Contact your doctor immediately if any of the following conditions are present:

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
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

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
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Blood Exposure
Persistent or increasingly severe headache
Vomiting
Unusual drowsiness or loss of consciousness
Drainage of blood or fluid from ear, nose or mouth
Convulsions
Weakness of limbs or loss of coordination
Blurred vision
Unequal pupils
Confusion or delirium
Disturbance of speech
Contact your doctor for medical evaluation or follow-up care due to blood borne disease transmission possibilities.
Wound
Cuts, punctures, and human or animal bites may require a tetanus shot to be administered. Within the next 24 hours, consult your doctor as to whether or not an injection for protection against lockjaw
(tetanus) is needed. The advice of your physician is important,
as this disease can be a consequence of even small injuries.
Last tetanus shot:
Insect Sting
Contact your doctor immediately if any of the following symptoms appear:
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

Breathing difficulty
Swelling of face, lips, or areas around eyes and ears
Itching
Rash
Wheezing
Injury - contact your doctor if any of these symptoms persist:

Immobility

Swelling

Pain

Illness - complaint of: _____________________________________________________________________________
Please call if you have any questions.
_____________________________________________
School Representative
_____________________________________________
School Site
____________________________________________
Phone
_____________________________________________
Date
fstadfup
Form: fstadfup
See following pages for forms--------- duplicate as needed
HEALTH SERVICES DEPARTMENT
FIRST AID FOLLOWUP INSTRUCTIONS
Dear Parent:
Your child,
was given first aid at_________a.m./p.m.
today, _________________, for _______________________________________________________.
date
Followup care by your family doctor may be important. Please follow carefully the instructions checked below:

Head Injury
Contact your doctor immediately if any of the following conditions are present:










Persistent or increasingly severe headache
Vomiting
Unusual drowsiness or loss of consciousness
Drainage of blood or fluid from ear, nose or mouth
Convulsions
Weakness of limbs or loss of coordination
Blurred vision
Unequal pupils
Confusion or delirium
Disturbance of speech

Blood Exposure Contact your doctor for medical evaluation or follow-up care due to blood borne disease
transmission possibilities.

Wound Cuts, punctures, and human or animal bites may require a tetanus shot to be administered. Within the next
24 hours, consult your doctor as to whether or not an injection for protection against
lockjaw (tetanus) is needed. The advice of your physician is important,
as this disease can be a consequence of even small injuries.
Last tetanus shot:

Insect Sting
Contact your doctor immediately if any of the following symptoms appear:






Breathing difficulty
Swelling of face, lips, or areas around eyes and ears
Itching
Rash
Wheezing
Injury - contact your doctor if any of these symptoms persist:

Immobility

Swelling

Pain

Illness - complaint of: _____________________________________________________________________________
Please call if you have any questions.
_____________________________________________
School Representative
_____________________________________________
School Site
____________________________________________
Phone
_____________________________________________
Date
fstadfup
DISTRITO ESCOLAR UNIFICADO DE LA CIUDAD DE SAN BERNARDINO
DEPARTAMENTO DE SERVICIOS DE SALUD
INSTRUCCIONES PARA EL SEGUIMIENTO DE PRIMEROS AUXILIOS
Estimados padres:
A sus hijos,
se le dio primeros auxilios a las________a.m./p.m.
hoy,___________________para ____________________________________________________________.
fecha
Pueda que el cuidado adicional por parte de su médico sea importante. Por favor siga cuidadosamente
las instrucciones marcadas debajo:

Daño a la cabezaComuníquese con su médico de inmediato si algunas de las siguientes condiciones están
presentes:










severo dolor de cabeza persistente o creciente
vómito
mareos anormales o la perdida del sentido
hemorragia de sangre u otros fluidos del oído, la nariz o la boca
convulsiones
debilidad en las extremidades o la perdida de la coordinación
visión borrosa
pupilas desiguales
confusión o delirio
alteración en el habla

Contacto con la sangre
Comuníquese con su médico para una evaluación o para cuidado adicional debido a la
posibilidad del contagio de una enfermedad trasmisible a través de la sangre.

Herida
Cortaduras, punciones y mordidas humanas o de animal pueden requerir una vacuna contra
el tétano. Consulte con su médico dentro de 24 horas para informarse si requiere una vacuna
para protegerse contra el tétano. Los consejos de su médico son importantes, ya que esta
enfermedad puede ser consecuencia hasta de pequeñas heridas.
Última vacuna del tétano:

Mordisco de insecto
Comuníquese con su médico de inmediato si aparece cualquiera de estos síntomas:






dificultad al respirar
hinchazón de la cara, los labios o áreas alrededor de los ojos y oídos
comezón, rasquera
sarpullido
resollo, silbido
Lesión – comuníquese con su médico si alguno de estos síntomas persiste:

Inmovilidad

Hinchazón

Dolor

Enfermedad – queja de: _____________________________________________________________________________
Por favor, llame si tiene preguntas.
_____________________________________________
Representante escolar
_____________________________________________
Plantel escolar
____________________________________________
Número telefónico
_____________________________________________
Fecha
COMMUNICABLE DISEASES AND INFESTATIONS
The Health Aide needs to be aware of communicable diseases that are often seen in the school aged child. This
is important because they are easily spread. The charts on the next few pages list some of these diseases and
methods to control them. Remember that many communicable diseases are rarely seen now due to newer
immunization practices.
1. Remember not to diagnose
2. Ask about others in the family
3. Refer the family to their own physician / health advisor
4. Call your School Nurse if more information is needed
5. Use the following charts as a guideline and for your own information
FIRST AID SUPPLIES
First Aid supplies are ordered through the school secretary. See the list of available vendors.
Suggested supplies:
Adhesive Tape
Band-aids
Cotton balls
Cotton tip Applicators
Gloves
Cold packs
Kleenex
Rolled Gauze 1”
Rolled Gauze 2”
Sterile dressings (gauze squares)
Safety pins
Scissors
Soap (liquid)
Thermometer – Digital or Thermal
Probe covers for thermometer
Paper cups
Tongue Blades
Triangular Bandages
Sharps container
Note: Do not order other First Aid supplies before you consult with Health Services or your school
nurse.
Recommended Vendors for Medical Supplies
Cintas (714-288-8400)
Call for current supply list
Medco School First Aid
www.medco-school.com
School Nurse Supply
www.schoolnursesupplyinc.com
Nasco Nursing and First Aid
www.enasco.com
Office Depot
www.officedepot.com
MacGill Discount School Nursing Supplies
www.macgill.com
FIRST AID KITS FOR CLASSROOMS
A First Aid Kit should be prepared for each classroom in a 3”x5” index-card type box.
It should include
Adhesive tape
Applicators
Band-aids
Cotton
Safety pins
Soap
Sterile gauze dressings
Directions for use
Gloves
FIRST AID SUPPLIES AND HOW TO USE THEM
1. Adhesive
2. 2x2 gauze
3. Band-aid
4. Cotton
5. Soap
Fasten dressings
Dressing for minor injuries
For small area protection
To prevent irritation or infection
Cleansing wounds, pressure pad
soft pads or dressing
For cleaning skin
and minor wounds
Kits should be kept clean and orderly and lid closed when not in use
Note: First Aid Kits for science laboratories, physical education, arts and crafts, cafeterias, homemaking, and
shops should be larger and also include scissors and tweezers.
FIRST AID FIELD KITS
First Aid Field Kits are usually made up in standard lunch boxes, or fanny packs that measure about 5”x7”x13”.
1. Be sure field kit is complete
2. Issue a field kit to the teacher before each field trip
3. Restock the field kit after each trip
4. Keep field kits easily accessible
Recommended supplies:
12- Sterile gauze (3x3)
4- Gauze roll bandages (1’’)
4- Triangular bandages
1- Roll adhesive tape (10yardsx1”)
1- Plastic bag
Gloves
Band-Aids
Wipes
Safety pins
Tongue blades
Cups
Kotex pads
RELIGIOUS EXEMPTION
Request for exemption from health-related requirements, first aid, or health screening, may be made
for religious reasons
1. Establish a file of these requests.
2. Make a note of this request on the Health Screen
3. Avoid any screening, non-essential first aid, or taking of temperature.
NOTE: These requests do not prevent excluding a sick child from school.
CHILD ABUSE
HEALTH AIDE RESPONSIBILITY
All school personnel are responsible for reporting suspected child abuse.
The Child Abuse and Neglect Reporting Act requires mandated reporters to complete and submit the form SS
8572 to CPS within 36 hours of receiving the information concerning the incident
Procedure:
1. Notify Child Protective Services (909) 384-9233 by telephone immediately to report the
incident or situation
2. Call Youth Services (880-6812) ask to get a District Case Number.
The reporter will give the Youth Services Department the name of the
of the report.
school and the date
Do not give your name or the name of the student. Do not send them a copy of the
report.
3. Fill out CPS form SS 8572 and send it to CPS. You can obtain this form from your school
site or online at:
http://www.caag.state.ca.us/childabuse/forms.htm
Read the instructions on the back of the form or on the web site on
how to fill it out. Make a copy for your records. Do not place a copy
in the students cum folder.
4. Mail the completed form to:
Child Protective Services
412 Hospitality Lane
San Bernardino, CA 92415
Form: SUSPECTED CHILD ABUSE REPORT
Number: SS 8572
See following pages
Make copies as needed
DENTAL SCREENING
Dental screening is recommended for K, 2, 5, and possible, but especially on all new students or those with a history
of uncorrected defects. Referral and follow up are essential parts of the screening process.
Screening may be done by:
1. CDHC Dentist
2. School Nurse
The Health Aid should
1. Send home DENTAL NOTICE prepared by school nurse
2. Provide dental resource list to parents
3. Record findings in AERIES
4. Follow up on care
5. Take every opportunity to explain brushing, flossing and routine care
6. Consult your school nurse regarding follow up on orthodontia needs
Note: Dental cavities and gum disease indicate an infectious process that may affect general health. This is a good place
to look for trouble in children with vague complaints and/or swollen neck glands.
See following page for DENTAL NOTICE
Superintendent
Kennon Mitchell, Ph.D.
Assistant Superintendent
Student Services Division
DENTAL NOTICE
TO THE PARENTS OF
:
In a recent dental screening it was determined that your child needs a further dental examination by
your family dentist. If you do not have a family dentist, a few options are listed below.
CHILDREN’S DENTAL HEALTH
CLINIC
580 West 6th Street
(909) 885-2045
Available for school children K-12th grades
who are not on Medi-Cal, have no other
dental insurance, and the family is low
income. Fee: $20.00 per visit.
Hardship cases receive special consideration.
SAC NORTON/DENTAL
CLINIC 1455 E. Third
St.
(909) 382-7120
Accepts Medi-Cal, Denti-Cal, and
Medicare. Clients with limited income may
qualify for sliding-fee scale, based on
income and family size.
Closed Fridays
(Pediatric Dental
Anesthesiologist)
Accepts Medi-Cal and IRC
clients.
Works with children with special
needs.
DR. RUSSELL SEHEULT
(Redlands Surgery Center)
1180 Nevada St #100
Redlands (909) 335-0474
MEDI-CAL DENTISTS
1-800-577-7318
WHITNEY YOUNG FAMILY
HEALTH CLINIC
(909) 386-7600
AMERICAN DENTAL
ASSOCIATION
Tri-County Dental Society
(909) 370-2112
BLOOMINGTON DENTAL
CLINIC
(909)-546-7530
LLU DENTAL
(909)-558-4675 15 years and
older
(909)-558-4689 Under 15
years
If you have any questions, please contact the Health Aide or Nurse at your child’s school.
Sincerely
12/12
School Nurse
Superintendent
AVISO DE LOS DIENTES
ESTIMADOS PADRES DE
:
Su hijo/hija requiere un examen de los dientes. Favor de comunicarse con su dentista. Por los que no tienen un
dentista de familia, hay las siguientes opciones.
CHILDREN’S DENTAL HEALTH CLINIC
580 West 6th Street
(909) 885-2045
Para los estudiantes de grados K-12 que no reciben Medi-Cal,
de una familia de ingreso bajo, y que no tengan seguro dental.
Precio: $20.00 por cada visita. Los casos de necesidad
recibirán consideración especial.
SAC NORTON/DENTAL CLINIC
1455 E. Third St.
(909) 382-7120
Aceptamos Medi-Cal, Denti-Cal, Medicare.
Personas con ingresos limitados pueden ser eligibles para
nuestro programa de descuentos en proporción a los ingresos
y tamaño de la familia.
DR. RUSSELL SEHEULT
(Redlands Surgery Center)
1180 Nevada St #100
Redlands (909) 335-0474
(Dentista Pediatra /Anestesiólogo).
Aceptamos Medi-Cal y clientes del IRC. Trabajamos
con niños que tienen necesidades especiales.
BLOOMINGTON DENTAL
CLINIC
(909)-546-7530
WHITNEY YOUNG FAMILY HEALTH CLINIC
LLU DENTAL
(909) 558-4675
(909) 558-4689
AMERICAN DENTAL ASSOCIATION
Tri-County Dental Society
(909) 370-2112
(909) 386-7600
MEDI-CAL DENTISTS
1-800-577-7318
Si tienen preguntas, pueden llamar a la enfermera o la asistente de la enfermera en la escuela de su hijo/hija.
Atentamente,
, Enfermera Escolar
12/12
Superintendent
Dear Parent or Guardian:
To make sure your child is ready for school, California law, Education Code Section 49452.8, now requires that
your child have an oral health assessment (dental check-up) by May 31 in either kindergarten or first grade,
whichever is his or her first year in public school. Assessments that have happened within the 12 months before your
child enters school also meet this requirement. The law specifies that the assessment must be done by a licensed dentist
or other licensed or registered dental health professional.
Take the attached Oral Health Assessment/Waiver Request form to the dental office, as it will be needed for your
child’s check-up. If you cannot take your child for this required assessment, please indicate the reason for this in Section
3 of the form. You can get more copies of the necessary form at your child’s school or online from the California
Department of Education’s Web site at http://www.cde.ca.gov/ls/he/hn/.
California law requires schools to maintain the privacy of students’ health information. Your child’s identity will not be
associated with any report produced as a result of this requirement.
The following resources will help you find a dentist and complete this requirement for your child:
1. Medi-Cal/Denti-Cal’s toll-free number or Web site can help you to find a dentist who takes Denti-Cal: 1-800-3226384; http://www.denti-cal.ca.gov. For help enrolling your child in Medi-Cal/Denti-Cal, contact San Bernardino
County Department of Public Health at (909) 387-6280 or at http://www.dhs.ca.gov/mcs/mediCalhome/CountyListing1.htm.
2. Healthy Families’ toll-free number or Web site can help you to find a dentist who takes Healthy Families insurance
or
to
find
out
if
your
child
can
enroll
in
the
program:
1-800-880-5305
or
http://www.healthyfamilies.ca.gov/hfhome.asp.
3. For additional resources that may be helpful, contact the local public health department Child Health and
Disability Prevention program at (909) 387-0400 or view the website at http://www.dhs.ca.gov/mcs/mediCalhome/CountyListing1.htm.
Remember, your child is not healthy and ready for school if he or she has poor dental health! Here is important advice to
help your child stay healthy:

Take your child to the dentist twice a year.

Choose healthy foods for the entire family. Fresh foods are usually the healthiest foods.

Brush teeth at least twice a day with toothpaste that contains fluoride.

Limit candy and sweet drinks, such as punch or soda. Sweet drinks and candy contain a lot of sugar, which
causes cavities and replaces important nutrients in your child’s diet. Sweet drinks and candy also contribute to
weight problems, which may lead to other diseases, such as diabetes. The less candy and sweet drinks, the
better!
Baby teeth are very important. They are not just teeth that will fall out. Children need their teeth to eat properly, talk, smile,
and feel good about themselves. Children with cavities may have difficulty eating, stop smiling, and have problems paying
attention and learning at school. Tooth decay is an infection that does not heal and can be painful if left without treatment.
If cavities are not treated, children can become sick enough to require emergency room treatment, and their adult teeth
may be permanently damaged.
Many things influence a child’s progress and success in school, including health. Children must be healthy to learn, and
children with cavities are not healthy. Cavities are preventable, but they affect more children than any other chronic
disease.
If you have questions about the new oral health assessment requirement, please contact Health Services (909) 880-6839.
Sincerely,
Assistant Superintendent, Student Services Division
Attachment
Superintendent
Estimado padre de familia o tutor legal:
Para asegurarnos que su hijo(a) está listo para ir a la escuela, El Código de Educación de California en el
artículo 49452.8, de ahora en adelante establece en la ley, que es obligatorio que su hijo(a) se someta a una
evaluación bucal (revisión dental) a más tardar el 31 de mayo, ya sea que se encuentre en primer grado o
kindergarten, cualquiera que sea su primer año en la escuela pública. También son aceptadas las evaluaciones que
se hayan efectuado en el transcurso de los 12 meses anteriores a la entrada de su hijo(a) a la escuela. La ley establece
que dicha evaluación tiene que ser efectuada por un dentista licenciado u otro profesional de salud dental que esté
licenciado o registrado.
Al llevar a su hijo(a) a la clínica para la revisión dental, será necesario que lleve el formulario para solicitar la
exención / evaluación de la salud bucal. Si usted no puede llevar a su hijo(a) esta evaluación obligatoria, por favor
indique la razón en la sección 3 del formulario. Usted puede obtener copias adicionales del formulario obligatorio, en al
escuela de su hijo(a) o en línea, en el sitio de la red cibernética del Departamento de Educación de California
http://www.cde.ca.gov/ls/he/hn/.
Las leyes de California obligan a las escuelas a mantener la información de salud de los estudiantes en forma
confidencial. La identidad de su hijo(a) no se incluirá en ningún informe que resulte como producto de la información
obtenida para cumplir con este requisito.
La siguiente información le ayudará a encontrar un dentista y de esta manera, su hijo podrá cumplir con este requisito:
4. El número de teléfono gratuito o el sitio de la red cibernética de Medi-Cal/Denti-Cal lo puede ayudar a encontrar
un dentista que acepte Denti-Cal: 1-800-322-6384; http://www.denti-cal.ca.gov. Para recibir ayuda con el proceso
de inscripción de su hijo(a)en Medi-Cal/Denti-Cal, comuníquese con el Departamento de Salud Pública del
Condado
de
San
Bernardino
al
(909)
387-6280
o
visite
http://www.dhs.ca.gov/mcs/mediCalhome/CountyListing1.htm.
5. El número de teléfono gratuito o el sitio de la red cibernética de Healthy Families puede ayudarlo a encontrar un
dentista que acepte seguro de Healthy Families, o si quiere obtener información acerca de las posibilidades que
tiene
su
hijo(a)
para
inscribirse
en
el
programa,
llame
al
1-800-880-5305
o
visite
http://www.healthyfamilies.ca.gov/hfhome.asp.
6. Para información adicional, comuníquese con el programa de Prevención de Incapacidades y Salud Pública en el
departamento de salud pública de la localidad al (909) 387-0400 o dele un vistazo al sitio de la red cibernética en:
http://www.dhs.ca.gov/mcs/medi-Calhome/CountyListing1.htm.
Recuerde, su hijo(a) no está saludable y listo para entrar a la escuela si posee una salud bucal ¡deplorable!
continuación le damos unos importantes consejos para ayudarle a mantener a su hijo(a) saludable:
A

Lleve a su hijo(a) al dentista dos veces al año.

Elija comidas saludables para toda la familia. Las comidas frescas usualmente son las saludables.


Asegurése que se cepille los dientes al menos dos veces al día con una pasta dental que contenga flúor.
Limite la cantidad de bebidas azucaradas tales como ponche o soda. Las bebidas azucaradas y los dulces
contienen mucha azúcar, causan caries y reemplazan nutrientes importantes de la dieta de su hijo(a). Los
dulces y las bebidas azucaradas también contribuyen a los problemas de peso que pueden producir otras
enfermedades, tal como la diabetes. ¡Es mucho mejor beber menos refrescos azucarados y comer menos
dulces!
Los dientes de leche son muy importantes. No son únicamente dientes que se caen. Los niños necesitan los dientes
para comer apropiadamente, hablar, sonreír y sentirse bien acerca de ellos mismos. Niños con caries tendrán dificultades
para comer, dejan de sonreír y tiene problemas para poner atención y aprender en la escuela. Las caries son infecciones
que no sanan y pueden ser dolorosas si no se les suministra tratamiento. Si las caries no se atienden, los niños se
pueden enfermar tan seriamente, que podrían necesitar ser atendidos en una sala de emergencia, y es posible que sus
dientes permanentes sufran un daño irreversible.
Hay muchas cosas que influencian el progreso y éxito del niño en la escuela, entre ellas la salud. Los niños deben estar
saludables para poder aprender, y los niños con caries no están saludables. Las caries aunque se pueden prevenir,
afectan a los niños más que otras enfermedades crónicas.
Si tiene alguna pregunta acerca del nuevo requisito de evaluación de salud bucal por favor comuníquese con los
Servicios de Salud (Health Services) al (909) 880-6839.
Sinceramente,
Asistente del superintendente
Departamento de Servicios del estudiante
Anexo
Oral Health Assessment Form
California law (Education Code Section 49452.8) states your child must have a dental check-up by April 30th of his/her
first year in public school. A California licensed dental professional operating within their scope of practice must perform
the check-up and fill out Section 2 of this form. If your child had a dental check-up in the 12 months before he/she starts
school, ask your dentist to fill out Section 2. If you are unable to get a dental check-up for your child, fill out Section 3.
Section 1: Child’s Information (Filled out by parent or guardian)
Child’s First Name:
Last Name:
Middle Initial:
Child’s birth date:
Address:
Apt.:
City:
ZIP code:
School Name:
Teacher:
Grade:
Child’s Sex:
□ Male
□ Female
Child’s race/ethnicity:
□ White
□ Black/African American
□ Hispanic/Latino
□ Asian
□ Native American □ Multi-racial
□ Other___________
□ Native Hawaiian/Pacific Islander □ Unknown
Parent/Guardian Name:
Section 2: Oral Health Data Collection (Filled out by a California licensed dental professional)
IMPORTANT NOTE: Consider each box separately. Mark each box.
Assessment
Date:
Caries Experience
(Visible decay and/or
fillings present)
Visible Decay
Present:
Treatment Urgency:
□ No obvious problem found
□ Early dental care recommended (Caries without pain or infection
□ Yes
□ Yes
□ Urgent care needed (pain, infection, swelling or soft tissue lesions)
□ No
□ No
Licensed Dental Professional Signature
or child would benefit from sealants or further evaluation)
CA License Number
Date
Section 3: Waiver of Oral Health Assessment Requirement
To be filled out by parent or guardian asking to be excused from this requirement
Please excuse my child from the dental check-up because: (Check the box that best describes the reason)
□ I am unable to find a dental office that will take my child’s dental insurance plan.
My child’s dental insurance plan is:
□ Medi-Cal/Denti-Cal
□ Healthy Families
□ Healthy Kids
□ Other ___________________
□ None
□ I cannot afford a dental check-up for my child.
□ I do not want my child to receive a dental check-up.
Optional: other reasons my child could not get a dental check-up:
If asking to be excused from this requirement: ____________________________________________________
Signature of parent or guardian
Date
The law states schools must keep student health information private. Your child's name will not be part of any report as a
result of this law. This information may only be used for purposes related to your child's health. If you have questions,
please call your school.
Return this form to the school no later than April 30th of your child’s first school year.
Original to be kept in child’s school record.
Regrese esta forma a la escuela antes del 30 de abril
Requisito de evaluación/exención de salud dental
La Sección 49452.8 del Código de Educación de la Ley de California ahora requiere que su hijo tenga un
chequeo dental antes del 30 de abril de su primer año escolar. Los chequeos dentales que se hayan
realizado dentro del período de 12 meses previo al inicio del año escolar, también son válidos. Si no
puede llevar a su hijo al chequeo dental, podrá obtener una exención para este requisito llenando la
Sección 3 de esta forma.
Sección 1 Deberá ser completada por el padre, la madre o el tutor
Section 2: Oral Health Data Collection To be completed by the dental professional conducting the
assessment
Primer nombre del menor:
Domicilio (número):
Nombre de la escuela:
Nombre del padre, madre o
tutor:
Apellido:
Inicial del
segundo
nombre:
Ciudad:
Grado escolar:
Fecha de
nacimiento del
menor:
Calle:
Código Postal:
Maestro:
Sexo del menor:
□ Masculino □
Femenino
Raza u origen étnico del menor:
□Blanco
□Negro/Afroamericano □Hispano/Latino □Asiático □Indio
nativo americano □Nativo de Alaska □Nativo de Hawai o de
isla en el Pacífico □Multi-racial □Desconocido
(Información de Salud Dental -a ser completado por el profesional dental)
Dental professional’s signature Date
Firma del profesional de salud dental:_________________________________ Fecha:____________
Assessment Date:
(fecha de evaluación)
Visible caries and/or
fillings present: □
Yes (sí) □ No (no)
Visible caries
present: □
Yes (sí) □ No
(caries visibles y/o empastes
presentes)
(no) (caries visibles
presentes)
El original será guardado en el registro escolar del menor.
Treatment Urgency (urgencia de tratamiento): □
No obvious problem found (ningún problema
obvio) □ Early dental care recommended (se
recomienda atención dental) □ Urgent care
needed (se necesita atención urgente)
Página 1 de 2
Regrese esta forma a la escuela antes del 30 de abril
Sección 3 Exención del requisito de evaluación de salud dental
Debe ser completado por el padre, la madre o el tutor que solicita ser disculpado de cumplir con este requisito
Solicito que mi hijo sea disculpado de cumplir con el requisito de evaluación de salud dental para
ingreso escolar debido a la siguiente razón: (Por favor marque el espacio que describe la razón)
□ No puedo encontrar un consultorio dental que acepte el seguro de mi hijo. Mi hijo está cubierto con el
seguro: □ Medi-Cal/Denti-Cal □ Healthy Families □Healthy Kids □Ninguno □Otro
□ No puedo pagar por el chequeo dental de mi hijo.
□ No quiero que mi hijo reciba un chequeo dental.
Opcional: otras razones por las cuales mi hijo no pudo obtener un chequeo dental:
_________________________________________________________________________
La ley de California requiere que las escuelas mantengan la privacidad de la información médica de los
estudiantes. La identidad de su hijo no será asociada con ningún reporte producido como resultado de
este requisito. Si tiene cualquier pregunta sobre este requisito, por favor contacte a la oficina de la
escuela.
Si pide dispensa de este requisite _______________________________________________
Firma del padre, madre o el tutor
Fecha
El original será guardado en el registro escolar del menor.
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Dental Assessment Survey
AB 1433 (Emmerson) was signed into law by the Governor as Education Code Section 49452.8. The
implementation date of this new law is January 1, 2007. The legislation requires that districts
collect, from each kindergarten student/ first time enrollees as first graders, proof of an oral
health assessment by May 31st each year.
The following report is due to my office by
December 1, 2008.
Please submit the following information via e-mail to
[email protected] or by fax (909) 386-2940 by this date. The first page of the
report should reflect a cumulative count on the required information from all sites in the
district. The following page can be duplicated as needed and should reflect information by
site.
District Name:
District Contact Person:
Position in District:
Phone Number:
E-mail:
Date of Submission:
Number of Sites Reporting:
DISTRICT TOTALS
1. Total Number of Pupils: (All kindergartners/first time enrolling first graders who are subject to
the requirement at this site.)
2. Total Number of Pupils who presented proof of a dental assessment:
3. Total Number of Pupils who failed to present proof of assessment due to financial burden:
4. Total Number of Pupils who failed to complete assessment due to lack of access to a
licensed dentist or dental health professional:
5. Total Number of Pupils who failed to complete an assessment due to parents or legal
guardian not consenting to their child receiving an assessment:
6. Total Number of Pupils assessed and found with untreated decay:
7. Total Number of Pupils who did not return either the assessment form or the waiver
request to the school:
Signature of Reporting Person: ________________________________________
Print Name: ___________________________
DATE:_____________
Dental Assessment Survey
SITE TOTALS
District Name: SBCUSD
Site Name:___________________
Site Contact Person:________________________
Phone:
Email:
Date of Submission:
Signature of Reporting Person: ________________________________________
1. Number of Pupils: (All kindergartners/first time enrolling first
graders who are subject to the requirement at this site.)
2. Number of Pupils who presented proof of a dental
assessment:
3. Number of Pupils who failed to present proof of assessment
due to financial burden:
4. Number of Pupils who failed to complete assessment due to
lack of access to a licensed dentist or dental health
professional:
5. Number of Pupils who failed to complete an assessment due
to parents or legal guardian not consenting to their child
receiving an assessment:
6. Total Number of Pupils assessed and found with untreated
decay:
7. Total Number of Pupils who did not return either the
assessment form or the waiver request to the school:
DIABETES
Diabetes is a potentially life threatening disease involving poor metabolism of glucose
Notify the School Nurse immediately of any students with this diagnosis
After inservice by the School Nurse, keep daily logs
Never attempt to manage this alone
Health Aides may not administer Insulin
Insulin reactions occur when the blood sugar level is too low.
Insulin and exercise lower blood sugar
Food raises blood sugar
Causes of insulin reactions
Too little food or delayed meal
Strenuous exercise- must adjust food or insulin
Too much insulin
Treatment
Check blood sugar and Doctors order
Give sugar containing substance and call nurse
Re-check blood sugar after additional snack or meal
See following pages for
Parent Consent and Physician Authorization
Carbohydrate-Insulin Documentation worksheet
HYPOGLYCEMIA/HYPERGLYCEMIA symptoms flyers
Superintendent
Date: _______________________
ATTN:______________________
RE:_________________________
Pupil Name
Attached you will find orders for Diabetes Management at School for the ___________school year.
You may substitute with your standard forms if they include all the necessary information.
Please complete the forms as soon as possible. If you have any questions, please contact me at the number
below.
Thank you for your prompt attention in this matter.
Sincerely,
_____________________________
School Nurse
Phone: 909-880-6839
Fax: 909-880-6846
Diabetes Management at School and School Sponsored Events
Parent Consent and Physician Authorization
DOB
Pupil
MIS #
SECTION I
Grade
School
Track
Physician’s Written Authorization: Check all boxes that apply
1. Blood Glucose Testing:
 Needs Assistance
 Before Meals
 As Needed
 By pupil
2  Care of Hypoglycemia When Below 70: See Section II
3. Emergency Care of Severe Hypoglycemia: See Section II

Glucose gel:
 Glucagon injection
 0.5 mgm
 1 mgm
4.Care of Hyperglycemia when:
 240 or above  300 or above
 Other:
 Student should drink 8 oz. of water every hour.
 Student is not to participate in P.E.
 Send student back to class.
If student has nausea, vomiting, or is lethargic, call
parent/guardian

Ketones should be checked if BG > 300
 By pupil independently  With Assistance
5. Insulin at school:
 Not at this time
 Routine lunchtime dose (see next column)
 Correction lunchtime dose (see next column)
 Carb Counting: _____# units per _____ gms Carbohydrate
 Morning Snack  Lunch  Afternoon snack
 NEEDS DIABETIC DIET AT SCHOOL
Other Needs (Specify):
If Insulin at school: Brand Name and Type:
Dose Preparation By:
 Pupil
 Parent
 Parent Designee
 School Nurse
Form Used:
 Pre-filled Syringe
 Insulin Pen
 Insulin Pump
 Inhaler
Written sliding scale as follows:
Blood Glucose from _______ to _______ = _______ Units
SQ Insulin Administered By:
 Pupil
 Parent
 Parent designee
 School Nurse
 Pupil with staff verification of Insulin Pen or Pump #.
(All parent designees are trained by the parent and are not
employees of the school or district.)
Parent must provide juice/Snacks for student at school, on all field trips or bus trips.
Parent Consent for Diabetes Management in School
We(I), the undersigned, the parent(s)/guardian(s) of the above-named pupil, request that the following specialized physical
health care service for management of Diabetes in school be administered to our (my) child in accordance with Education Code
Section 49423.5 I will:
1. Provide the necessary supplies and equipment.
2. Notify the school nurse if there is a change in pupil health status or the attending physician.
3. Notify the school nurse immediately and provide new consent for any changes in doctor’s orders.
I authorize the school nurse to communicate with the physician when necessary.
Parent/Guardian Name (Print)
Signature
Date
Physician Authorization for Diabetes Management In School
My signature below provides authorization for the above written orders. I understand that all procedures will be implemented
in accordance with Education Code Section 49423.5. I understand that specialized physical health care services may be
performed by unlicensed designated school personnel under the training and supervisioin provided by the school nurse. This
authorization is for the __________________________ school year.
Physician Name (Print)
Signature
Date
Address
Phone
City
Zip
FAX
Reviewed by School Nurse (Signature)_______________________________________________ Date________________
Diabetes Management at School and School Sponsored Events
SECTION II PROTOCOLS
TREATMENT OF LOW BLOOD SUGAR
CONSCIOUS
If hypoglycemic symptoms are present student must be
supervised AT ALL TIMES
Page 2
< 70
SEMICONSCIOUS (ABLE TO SWALLOW)
1.Squirt instant glucose between gum & cheek.
.
1.Give student one of the following carbohydrate selections:
Any type of simple carbonated beverage equivalent to
15-20 grams carb., i.e. 4-6 oz juice, regular soda,
Kool Aid, or punch.
3 glucose tablets
1 cup milk
2.Wait 5-10 minutes for symptoms to subside.
3.Recheck blood glucose level
If BG level > 80 Send to lunch or give carb. & protein
snack (example: cheese and crackers) and student
may return to scheduled class routine.
If BG level < 80 Repeat Steps 1 and 2. If student’s
symptoms have subsided after 5 – 10 minutes
proceed to snack or lunch follow-up.
If symptoms of hypoglycemia are still present repeat
Steps 1 and 2 and call parents
1.Mix glucagon with liquid diluent.
2.Withdraw up solution
3.Give injection in muscle (leg or arm) & turn student on side.
4.Call: 911 and parent and School Nurse.
Any Other Instructions:
GLUCAGON
Low blood sugar or insulin reaction may cause the student to go into a seizure or lose consciousness
What will I see?
Symptoms of low blood sugar are: hunger, sleepy, shaky, sweaty, spacey, and stubborn. Severe low blood
sugar may cause a seizure or loss of consciousness. Student will not be able to eat or drink safely.
How can I help?
1. Call 911, parent and school nurse
2. Get the student’s glucagon kit. Check the expiration date.
3. Take off the safety cap on the syringe and the vial of dry powder
4. Inject all the liquid contents of the syringe into the vial of dry powder
5. Remove syringe and shake bottle gently until glucagon dissolves and the solution
becomes clear
6. Re-insert syringe and draw out liquid:
0.5 mg if child weighs less than 44 pounds,
1mg for adults and children over 44 pounds.
7. Remove syringe from bottle. Get air out of syringe
8. Inject syringe straight into the muscle of arm, thigh or buttock. No need to remove clothing
9. Turn the student on their side, in case of vomiting
Emergency Medication
Glucagon
How to administer
1. Check expiration date.
2. Take off safety cap on syringe and vial of dry
powder, inject liquid into dry powder and mix.
3. Draw out liquid into syringe and inject into muscle
of arm, thigh or buttocks.
4. Turn student on side.
5. Call 911, school nurse and parent.
San Bernardino City Unified School District
STUDENT CARBOHYDRATE-INSULIN CALCULATION WORKSHEET
Student Name______________________________ MIS #_____________ Date____________
1. My pre-lunch blood sugar is _______________________.
2. My lunch today is:
o Food item__________________________________ Carbohydrates_____________
TOTAL CARBOHYDRATES I WILL EAT:______________________
3. My insulin to carbohydrate (CHO) ratio is:
o 1:10
o 1:15
o 1:20
INSULIN
Ratio
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
CARBS
1:10
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
INSULIN
Ratio
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
CARBS
1:15
15
23
30
38
45
53
60
68
75
83
90
93
105
113
120
INSULIN
Ratio
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
CARBS
1:20
20
30
40
50
60
70
80
90
100
110
120
130
140
150
160
4. Do I need to subtract insulin (if my blood sugar is less than _______)? __________________
5. Do I need to add insulin (if my blood sugar is over _______)? ________________________
6. How many units of insulin do I give? (total =insulin for meal + insulin for BS) ________
7. I gave ___________units of insulin at ______________ (time).
FIRST GRADE PHYSICALS
California State Law (Health and Safety Code, Section 323.5, 324.5) requires all students have a physical examination
for entry into first grade.
The parent/guardian of a student who has attended Kindergarten in the San Bernardino City Unified School
District must provide appropriate documentation that a physical examination has been completed within 18
months prior to the date of enrollment into first grade. Students coming from another school district or another
state have 90 days to get established with a local physician and obtain a physical exam/health screening.
In the absence of documentation of the physical examination, the student will be excluded from school for not
more than five school days. Admittance will be permitted on the sixth day. Following admittance, continued
efforts are to be made to encourage the parent/guardian to obtain the physical examination.
During the five-day exclusion period, classroom space at a specific school cannot be guaranteed. As a result
of insufficient classroom space, a student returning from the exclusion period may have to be placed in another
school within the district.
There are rare occasions when a parent cannot or will not obtain a physical for their child. In this case, the
parent is asked to sign a Waiver of Health Examination for School Entry indicating the reason.
If the parent indicates that they have been “unable” to obtain the physical, the Health Aide should assist them
in doing so.
See following pages for forms:
First Grade Physical Requirement
First Grade Physical Examination Exclusion Letter
Report of Health Exam
Clinics in San Bernardino
First Grade Physical Waiver
Superintendent
To Parent or Guardian of: ____________________________________
California State Law (Health and Safety Code, Sections 124040-124105) requires all students have a physical
examination prior to entry into first grade or within 90 days if the student is coming from another school district
or another state. The Child Health and Disability Prevention Program established this law because early
identification and treatment of health conditions can prevent irreversible damage which can affect your child’s
health and well being.
The physical exam must be done within 18 months before entry into first grade. This means the physical should
have been done on or after ___________________________________________.
As of this date, we do not have a copy of a physical in your child’s records. If we do not receive a copy of
the physical before the end of the School Year, your child will be EXCLUDED on the 1st day of School.
We understand how important it is for your child to attend school everyday so we hope that you will make an
appointment and get us a copy of the physical exam immediately. Here are some resources for obtaining a
physical exam:
1. Your private physician or health care provider
2. San Bernardino County Health Dept. Well Child Clinic (1-800-722-3777)
Please contact the school office if you have any difficulty or questions.
Thank you for letting us help keep your child healthy!
Sincerely,
Angela Jones, R.N., M.A.
Coordinator, Health Services
7/9/12
Superintendent
Para el padre o tutor legal de: ___________________________
La ley del Estado de California (Artículos 124040-124105 del Código de Salud y Seguridad) requiere que todos
los alumnos reciban un examen físico antes de ingresar al primer grado o dentro de los 90 días si el alumno
viene de otro distrito escolar o de otro estado. El Programa de Salud y Prevención de la Discapacidad Infantil
estableció esta ley porque la identificación y el tratamiento de las condiciones de salud a una etapa temprana
pueden prevenir el daño irreversible que puede afectar la salud y el bienestar del niño.
El examen físico debe realizarse dentro de los 18 meses antes de ingresar al primer grado. Esto significa que el
examen físico debió hacerse el o después del_____________________________.
A partir de esta fecha, no tenemos una copia del examen físico en el expediente de su hijo. Si no
recibimos una copia del examen físico antes del Fin del Ano Escolar, su hijo será EXCLUIDO el Primer
dìa de la Escuela.
Entendemos la importancia de que su hijo asista a clases todos los días, así que esperamos que haga una cita y
nos entregue una copia del examen físico inmediatamente. A continuación están algunos recursos para obtener
un examen físico:
1. Su médico de cabecera o proveedor de asistencia sanitaria
2. La Clínica para Niños Sanos del Dpto. de Salud del Condado de San Bernardino (1-800-722-3777)
Favor de comunicarse con la oficina de la escuela si tiene cualquier dificultad o pregunta.
¡Les damos las gracias por permitirnos mantener a su hijo sano!
Atentamente,
Coordinadora, Servicios de Salud
7/6/11
Superintendent
First Grade Physical Examination Exclusion Letter
Dear Parent/Guardian of _______________________________:
California State Law (Health and Safety Code, Section 323.5, 324.5) requires all students have a physical
examination for entry into first grade.
As of this date, we do not have a copy of a physical examination in your child’s records. Your child is being
excluded from school effective ___________________ for a maximum of five (5) school days.
If your child has not had a physical examination in the last 18 months prior to first grade entry, please make an
appointment as soon as possible with one of the following:
1. Your private physician or health care provider
2. San Bernardino County Public Health Dept. (1-800-722-3777)
When the physical examination has been completed, please bring a copy to the school as soon as possible.
Please contact the school office at ______________________ if you have any questions.
Sincerely,
AJ:nm
7/12
Superintendent
Examen Físico para Alumnos del Primer Grado – Carta de Exclusión
Estimados Padres/Encargados de ______________________
__
La Ley Estatal de California (Sección 323.5, 324.5 del Código de Salud y Seguridad) requiere que todos los
estudiantes tengan un examen físico para entrar al primer grado.
Hasta esta fecha, no tenemos una copia de un examen físico en el expediente de su hijo. Su hijo será excluido
de la escuela a partir del ___________________________ por un máximo de cinco (5) días escolares.
Si su hijo aún no ha tenido un examen físico en los últimos 18 meses antes de la entrada al primer grado, por
favor hagan una cita lo más pronto posible con uno de los siguientes:
1. Su médico privado o proveedor de cuidados médicos
2. Clínica de Bienestar Infantil del Departamento de Salud del Condado de San Bernardino (1-800722-3777)
Cuando hayan terminado con el examen físico, por favor traigan uan copia a la escuela lo más pronto posible.
Favor de ponerse en contacto con la oficina escolar al _____________________ si tienen cualquier pregunta.
Atentamente,
Coordinadora, Servicios a la Salud
Traducido por: Rosa María Equihua
11/2011
CLINIC SERVICES IN SAN BERNARDINO
La Salle Pediatric Medical Group
La Salle Medical Clinic
1505 W. 17th Street
909-887-6494
565 N. Mt Vernon Ave
909-884-9091
M-F 8am-5pm
Walk-ins welcome at both clinics
SAC Norton
SAC Frazee
1455 E. Third St
909-382-7100
M-F 8am-5pm
SAC Arrowhead
488 S. K St
909-383-8092
1293 N. D Street
909-381-1663
Mon.-Thurs.7:30am-5pm
Mon &Thurs. only 8am-12, 1pm-5pm
Mon-Thurs. 8am-4:30pm
Walk-ins 8am-9:30am / 1pm-3:30pm
Closed Fridays
Closed Fridays
SAC Dental Clinic 909-382-7120 Mon-Thurs 7am-6pm
Metropolitan
742 W. Highland Ave
Between G & H Streets
909-881-7320
Mon.- Fri. 8am-7pm
Metropolitan
Metropolitan
1574 W. Baseline Ave # 107
near Medical Center
909-386-1880
Mon-Fri. 8am-5pm
Sat. 9am-2pm
7576 Sterling Ave
corner of 9th
909-381-8983
Mon-Fri. 8am-5pm
All three clincs: Walk-ins for Physicals and Immunizations- Mon.- Fri. 8am-10am, 1pm-3pm
*Metropolitan clinics provide transportation* (call 1 day in advance 909-386-1880)
Inland Family Community Health Center
San Bernardino Public Health Center
665 N “D” St
799 East Rialto Ave
909-708-8158
M-F 8am-5pm (closed for lunch 11am-1pm)
M-F 8am – 5pm
1-800-722-4777
Urgent Care 5pm-9pm
Walk-ins Sat 9am-6pm
Sports Physicals (call for current fees and options for low income)
Dental care provided 8am-5pm for low income and IEHP
Inland Behavioral Health Services (IBHS)
1963 N. E Street
909-881-6146
M-F 8am-5pm
No walk-ins
Al-Shifa Free Clinic
2034 Mallory St
909-473-9342
Call for appt and hours
Phoenix Clinic (dept of behavioral health)
820 E Gilbert St
909-387-7200
Walk-ins Mon.-Tue. &Thur. 8am-10am
Serves ages 6-Adult
Immediate crisis CCRT 909-387-7645
Inland EmpireCommunity Health Clinic
18601 Valley Blvd
909-877-0510
Mon.-Fri 8am-5pm
Walk-ins 8am-10am & 1pm-3pm
Inland Empire Inc.
Whitney Young Clinic
1755 Maple Street
909-386-7600
Mon.-Fri. 8am –5pm
Walk-ins 8am-5pm
McKee Clinic
1998 N Arrowhead Ave
401 E Highland Ave # 552
2372 Sterling
Mon.-Fri. 8:30am-5:30pm Mon.-Fri. 8:30am-5:30pm
Appt: 909-422-8029
Walk-ins and Appt
Walk-ins and Appt
Open M-F 8am-5pm
909-882-0988
909-883-8058
Walk -ins ok
Walk-ins:8:30-11:30 and 1:30-4:00
Evening appts call 422-8029 6pm-9pm
Accepts most insurances
(Arrowhead Medical Center schedules the appointments for McKee)
Updated: April 1, 2012
IMMUNIZATIONS
Certai n i mmu n i zati on s are req u i red b y l aw f or en tran ce i n to sch ool
Help parents determine immunization status
Assist parents in obtaining necessary immunizations
Prepare and keep a record of immunizations that are needed
Update immunization history on the blue immunization card and in aeries
Notify parents of needed immunizations using the “Notice of Inadequate
Immunizations” forms
Flag records of students with medical or personal beliefs waivers
ADMINISTRATION
Policy No. 2331.ab
IMMUNIZATION REQUIREMENT FOR SCHOOL ADMISSION
IMMUNIZATION REQUIREMENT FOR SCHOOL ADMISSION
Pupils under the age of 18 years who enter or transfer into the District must present an immunization record which shows that the pupil has received the immunizations
required by California State Law.
District Procedures
A.
B.
C.
D.
Unconditional Enrollment
1.
No pupil shall be admitted to the District without presenting an immunization record which shows that the pupil has received the State required
immunizations.
2.
Exceptions
a.
The parent/guardian may exempt the pupil based upon their personal beliefs.
b.
The pupil’s licensed physician may provide a written statement exempting the pupil from immunizations for medical reasons.
c.
In the event of an outbreak of a contagious disease, exempted students will be excluded from school as directed by the local Health
Department.
Conditional Enrollment
1.
Pupils who have not completed an entire series of medication for a required immunization, but who are up to date with required doses, may be
admitted on the condition that they complete the immunization as prescribed.
2.
A pupil whose physician provides a written statement postponing one or more immunizations because of a medical condition may be admitted on
the condition that the needed dose(s) will be obtained when the exemption expires.
Transfer Students Without Cumulative Records
1.
Transfer students whose parents are unable to present an adequate immunization record will be enrolled but not admitted to school.
2.
School personnel shall assist parents who are unable to obtain immunization records by contacting the previous school for telephone verification.
If verified then the student shall be admitted.
Unmet Requirement Found After Admission
If, after a pupil is admitted to school, it is discovered that one or more immunizations are lacking, the parent will be notified and given not more than 10
school days to obtain the immunization(s) and present documentation that the immunization(s) were received. If the parent does not present the record
within 10 days after notification, the pupil must be excluded from school.
E.
District Follow up
1.
The schools within the District will review the records of pupils admitted conditionally every 30 days and notify parents if immunizations are
required.
2.
The notification to the parent will include a statement that a record of immunization(s) must be received within
and that if no record is received, the student will be excluded from school.
10 school days of the due date
GUIDE TO IMMUNIZATIONS REQUIRED FOR SCHOOL ENTRY
Grades K-12
INSTRUCTIONS Post this guide on a wall or desktop as a quick reference to help you determine whether children seeking admission to your school meet California's school
immunization requirements. If you have any questions, call the Immunization Coordinator at your local health department.
REFERENCE Health and Safety Code, Division 105, Part 2, Chapter 1, Sections 120325-120380; California Code of Regulations, Title 17, Division 1, Chapter 4, Subchapter
8, Sections 6000-6075
IMMUNIZATION REQUIREMENTS
To enter or transfer into public and private elementary and secondary schools (grades kindergarten through
12), children under age 18 years must have immunizations as outlined below.
VACCINE
REQUIRED DOSES
Polio
4 doses at any age, but... 3 doses meet requirement for ages 4–6years if at least one
was given on or after the 4th birthday1; 3doses meet requirement for ages 7–17 years if at
least one was given on or after the 2nd birthday.1
Diphtheria, Tetanus, and Pertussis
Age 6 years and under (Pertussis is required)
DTP, DTaP or any combination of DTP or
DTaP with DT (diphtheria and tetanus)
5 doses at any age, but... 4 doses meet
requirements for ages 4–6years if at least one was
on or after the 4th birthday.
Age 7 years and older (Pertussis is not required)
Td, DT, or DTP, DTaP or any combination
of these
4 doses at any age, but...3 doses meet
requirement for ages 7–17 years if at least one
was on or after the 2nd birthday.1 If last dose
was given before the 2nd birthday, one more (Td) dose is required.
th
Tdap 7 Grade – Pertussis
1 dose- all students entering, advancing or transferring into 7th grade will need proof
of a Tdap immunization. Meets requirement if last dose was given on or after 7 th birthday
and it contained pertussis (Tdap, Adacel, Boostrix, Dtap, DTP)
Measles, Mumps, Rubella (MMR)
Kindergarten
7th grade
Grades 1–6 and 8–12
2 doses2 both on or after 1st birthday. 1
2 doses2 both on or after 1st birthday. 1
1 dose must be on or after 1st birthday. 1
Hepatitis B
Kindergarten
7th grade
3 doses at any age
3 doses3 at any age
Varicella
Kindergarten
Out-of-state entrants (grades 1–12)
1 dose4
1 dose for children under 13 years; 2 doses are needed if immunized on or
after 13th birthday. 4
The law allows (a) parents/guardians to choose an exemption from immunization requirements based on their personal beliefs, and (b) physicians of children to elect medical
exemptions. The law does not allow parents/guardians to elect an exemption simply because of inconvenience (a record is lost or incomplete and it is too much trouble to go
to a physician or clinic to correct the problem). See the back of the blue California School Immunization Record (PM 286) for instructions and the affidavit to be signed by
parents/guardians electing the personal beliefs exemption. For children with medical exemptions, the physician's written statement should be stapled to the CSIR. Schools
should maintain an up-to-date list of pupils with exemptions, so they can be excluded quickly if an outbreak occurs.
1 Receipt of the dose up to (and including) 4 days before the birthday will satisfy the school entry immunization
requirement.
2 Two doses of measles-containing vaccine required. One dose of mumps and rubella-containing vaccine required;
mumps vaccine is not required for children 7 years of age and older.
3 Two doses of the 2-dose hepatitis B vaccine formulation along with provider documentation that the 2-dose hepatitis B
doses and both doses were received at age 11–15 years will also fulfill this requirement.
4 Physician-documented varicella (chickenpox) disease history or immunity meets the varicella requirement.
vaccine formulation was used for both
Check List for Evaluating Immunization Records
1. Polio - (OPV or IPV)
Spanish – Sábin
2. DPT - (Diphtheria, Tetanus, Pertussis, or combination of DTaP/DT/td)
English
Diphtheria
Tetanus
Pertussis
Spanish
Difteria
Tetano
Pertusis
Pentavalente- DPT + HepB + Hib
3. MMR - (Measles, Mumps, Rubella) (Trivalent or Triviral)
English
Measles
Mumps
Rubella
Spanish
Sarampión
Paperas
Rubeola
4. Hepatitis B- (Recorded as HBV, Recombivax, Engerix,
HBVac,Comvax, Hep HCV)
5. Hepatitis A - (Recorded as Havrix, Vaqta HAV) (not required for K-12entry)
6. Varicella - VAR,Varivax (chickenpox)
7. HIB - HIBPEDVX – PRP OM – Pedvax- Haemophilus Influenzae type b
(not required for K-12entry)
8. Prevnar- PCV- pnuemococcal (not required for K-12entry)
COMBINATION VACCINES
Kendrix: Polio + Dtap
PentactHib: Polio+ HIB + DPT
Pdrix, Pediarix, IHBDPT: DTap + IPV + Hep B
HEBHCV, HepHCV, Comvax: HIB + HepB
ProQuad, MMRV: MMR + Varicella
IMMUNIZATION: EXEMPTION /WAIVER
A student may be exempt from immunization on a temporary or permanent basis for a variety of
reasons.
1.
Obtain the parent or guardian signature on the back of the blue immunization card
2.
Obtain a physician’s request for medical reason and staple to the blue immunization card
3.
Document the Exemption/Waiver in Aeries
4.
Make note of these students on the immunization follow-up paper
5.
Inform the parent that in case of an outbreak of a contagious disease, the
student will be
exempt from school during the incubation period of that disease or until the child receives the
appropriate immunization
NOTE: The person enrolling the student is responsible to mark and sign the immunization
record
FORM: California School Immunization Record PM- 286
(Blue Immunization Record)
CALIFORNIA SCHOOL IMMUNIZATION LAW
EXEMPTIONS INFORMATION SHEET
Here is information about exemptions from the immunizations required by the California School Immunization Law.
The Law allows these exemptions.
*1. PERMANENT MEDICAL EXEMPTION: If your child has a medical condition which permanently rules out
one or more vaccines, your child can be exempted from that immunization(s) requirement. A written statement from
a physician must be presented at registration. It must state that there is a medical condition which permanently rules
out immunization(s), and which immunization(s) your child cannot receive. It must be signed by the physician.
*2. TEMPORARY MEDICAL EXEMPTION: If your child has a temporary medical condition which rules out one
or more immunizations, or your physician wishes to delay an immunization, your child can be temporarily exempted
from the requirement. A written statement from the physician must be presented at registration. This statement must
indicate that there is a medical condition which rules out immunization(s) temporarily, how long it will last, and
which immunization(s) must be postponed. It must be signed by the physician.
3. MEASLES DISEASE EXEMPTION: If a physician provides a written statement that your child has had measles
disease, your child can be exempted from the measles requirement. The signed statement must be presented at
registration.
4. RUBELLA DISEASE EXEMPTION: If a physician provides a written statement that your child has had
laboratory-confirmed rubella disease, your child can be exempted from the rubella requirement. The signed
statement must be presented at registration.
5. MUMPS DISEASE EXEMPTION: If a physician provides a written statement that your child has had
laboratory-confirmed mumps disease, your child can be exempted from the mumps requirement. The signed
statement must be presented at registration.
6. VARICELLA (CHICKENPOX) EXEMPTION: If a physician has documented that your child has had
chickenpox disease, your child can be exempted from the varicella requirement.
The immunization record showing physician documentation must be presented
at registration.
*7. PERSONAL BELIEFS EXEMPTION: If immunization is against your religious or personal beliefs, you will
be asked to sign an affidavit at the time of registration. Your child will then be exempt from the immunization
requirements.
*NOTE: If your child is exempt because of 1, 2, or 7 above, and there is a disease outbreak, the school may be ordered by the Health
Department to temporarily exclude your child for his/her protection.
The California Health and Safety Code, Division 105, Part 2, Chapter 1, Sections 120325-120380 establishes the immunizations
required and exemptions. Regulations to implement the law are contained in the California Code of Regulations, Title 17, Division 1,
Chapter 4, Subchapter 8, 6000-6075.
IMM-488E (5/02)
NOTICE OF INADEQUATE IMMUNIZATION
Student’s Name _______________________________MIS# _____________ Date ___________
School_________________________________________________________________________
Dear Parent/Guardian:
Our records indicate that your child needs one or more immunizations to meet the requirements of the California School
Immunization Law. (Health and Safety Code Section 120325-120375)
By state law, your child cannot be allowed to attend school without a legally acceptable record of the needed
immunization(s). IF YOU DO NOT PROVIDE DOCUMENTATION OF THE NEEDED IMMUNIZATION(S)
WITHIN 10 DAYS OF THE ABOVE DATE, YOUR CHILD WILL BE EXCLUDED FROM SCHOOL
EFFECTIVE ________________________________.
Required immunizations – Dates of documented doses are included. Needed immunizations are circled.
POLIO
1 _________ 2 _________ 3 _________ 4 _________
DPT/DT
1 _________ 2 _________ 3 _________ 4 _________ 5 _________
Tdap/DTap/DPT
1 _________ (pertussis booster given on or after 7th birthday)
MMR
1 _________ 2 _________ 3 _________
HEPATITIS B
1 _________ 2 _________ 3 _________
VARICELLA
1 _________ 2 _________
HIB
1 _________ 2 _________ 3 _________ 4 _________
YOU WILL NEED TO TAKE THE FOLLOWING ACTIONS:
1. Take your child and this form to your physician, a school district clinic, or the local health department to obtain the required
immunization(s) and/or records. Bring the immunization record to the school.
2. If your child has received the needed immunization(s), bring his/her immunization record to the school. Your child’s records must
show the month, day, and year for the immunizations circled above.
3. If immunizations are against your personal beliefs, please come to the school and sign an exemption statement.
4. If any immunizations were not given to your child because of medical reasons, please bring a letter, signedby your doctor, to the
school.
Thank you for your part in complying with the law and ensuring the health of our students. If you have any questions or required
additional information, please call _______________________________.
Sincerely,
HEALTH SERVICES
PPS-24 (Rev. 7/11)
División de Servicios Estudiantiles
AVISO DE INMUNIZACIÓN INADECUADA
Nombre del estudiante __________________________ MIS # ____________ fecha _______________
Escuela_____________________________________________________________________________
Estimados padres /tutores legales:
Nuestros registros indican que su hijo necesita una inmunizacion o más para cumplir con los requisitos de la Ley de
Inmunizaciones Escolares de California. (Artículo 120325-120375 del Código de Salud y Seguridad)
Según la ley estatal, a su hijo no se le permitirá asistir a la escuela hasta que un registro legalmente aceptable sea
presentado acerca de las inmunizaciones necesarias. SI NO PROVEEN LA DOCUMENTACIÓN DE LAS INMUNIZACIONES
NECESARIAS DENTRO DE 10 DÍAS DE LA FECHA INDICADA ARRIBA, SU HIJO SERÁ EXCLUIDO DE LA ESCUELA A PARTIR
DE ____________________________________________________ .
Inmunizaciones requeridas - Las fechas de las dosis documentadas están incluidas. Las inmunizaciones necesarias
están marcadas con un círculo.
POLIO
1 _________ 2 _________ 3 _________ 4 _________
DPT/DT
1 _________ 2 _________ 3 _________ 4 _________ 5 _________
Tdap/DTap/DPT
1 _________ (vacuna de refuerzo de pertusis dada en o después su 7º cumpleaños)
MMR
1 _________ 2 _________ 3 _________
HEPATITIS B
1 _________ 2 _________ 3 _________
VARICELLA
1 _________ 2 _________
HIB
1 _________ 2 _________ 3 _________ 4 _________
ES NECESARIO QUE USTEDES TOMEN LAS SIGUIENTES ACCIONES:
1. Llévenle este formulario a su médico, a la clínica del distrito escolar o al departamento local de salud para conseguir las
inmunizaciones y/o los registros requeridos. Traigan el registro de inmunizaciones a la escuela.
2. Si su hijo ha recibido las inmunizaciones necesarias, traigan el registro de inmunizaciones de éste a la oficina
escolar. Los registros de su hijo deberán proveer el mes, día y año para las inmunizaciones marcadas
arriba con un círculo.
3. Si las inmunizaciones están en contra de sus creencias personales, por favor pasen a la oficina escolar para
firmar una declaración de exención.
4. Si cualquier inmunización no se dio a su hijo debido a razones médicas, por favor traigan a la escuela una carta
firmada por su médico.
Gracias por ayudarnos a cumplir con la ley y asegurar la salud de nuestros estudiantes. Si tienen cualquier pregunta
o requieren información adicional, por favor llamen al _________________________
Atentamente,
HEALTH SERVICES/SERVICIOS DE SALUD
PPS-25 (Rev. 7/11)
LICE- (Pediculosis)
Lice can sometimes be seen crawling on the scalp, but most common symptoms are scratching and the nits or
eggs. Nits will usually be found within ½ inch of the scalp behind the ears at the nape of the neck, or at the
base of a ponytail
 Screen and monitor students who are suspected as well as siblings.
 Conduct periodic school wide screenings.
 Provide health education materials to school personnel as necessary. Contact your school nurse for
assistance.
 For chronic head lice cases, or if a family is having trouble removing all the nits, discuss with your
school nurse.
 Notify parent/guardian that the student(s) must be excluded from school until properly treated and
clear of nits. Pediculosis is recognized as a communicable disease.
 Advise parent about correct treatment and the importance of doing all of the following:
Use of lice shampoo according to directions on package.
Removal of all nits.
Thorough cleaning of clothing, bed, stuffed toys, house, car, hair
Brushes/combs, etc.
Treatment of all family members and infected friends.
Lice shampoo is available at most drug stores.
REMOVAL OF NITS
Removal of all the lice is the only way to assure the problem has been adequately treated and to be certain
that no viable nits are present. This is accomplished only by hand removal or use of a special comb to
remove the nits:
While hair is still wet, start at the top of head
Comb a few strands of hair at a time (too much hair spreads the teeth of the nit comb and the
nits just slide through)
Use a hair clip to hold clean hair
Continue working down and around, keeping clean hair on top of head
Cleaning of the home:
All washable clothing, bedding and toys should be washed in hot water
Use a dryer for all items that can be dried
Wash all combs/brushes in hot soapy water for 5-10 minutes
Vacuum mattresses, furniture, floors and car
Commercial sprays are available, but can be expensive
Pillows and other items that cannot be washed or put in dryer, should be enclosed in a clean
plastic bag, sealed for up to 2 weeks
HEAD LICE
1.
WHAT ARE HEAD LICE?
A head louse is an insect that lives on the human scalp and feeds on blood. The eggs lice lay on the
hair are called nits.
Hatches in 7-10 days
II.
III.
IV.
V.
HOW DOES SOMEONE GET HEAD LICE?
A.
The insect can crawl from one person’s head to another (they do not jump or fly).
B.
They may be spread by anything that touches your scalp.
C.
Nits hatch in 7-10 days after they are laid on the hair.
WHAT SIGNS SHOULD I LOOK FOR?
A.
Itching. (May not always be present.)
B.
Look for nits attached to individual hairs. Nits may resemble a small grain of rice unlike
dandruff or hair spray, nits are very difficult to remove.
C.
Sometimes you may see the actual louse, a small insect that blends with your hair color.
TREATING HEAD LICE!
A.
Use a lice-killing shampoo. There are good prescription and nonprescription products.
Always follow package directions!
B.
You must remove all nits before the student returns to school. The best way to remove nits
is to part the hair in small sections. It is recommended to use a metal nit comb with long
teeth. Continue to comb their hair every day with the nit comb for 2 weeks.
C.
Your house must be treated too:
Wash in hot, soapy water all linens and clothing.
Vacuum carpeting, mattresses and furniture. Mop floors.
Nonwashable items can be dry-cleaned or put away in plastic bags for at least 2 weeks.
HOW MAY I HELP PREVENT HEAD LICE IN THE FUTURE?
All family members should avoid borrowing personal items: combs, brushes, hats, towels or
clothing from each other or from friends. It is best for everyone to use ONLY his or her own
personal articles.
One Female Louse
Plus
30 Days
Equals
100 Baby Lice
Concerned & Informed Parents
Plus
Effective Lice Control
Equals
NO BABY LICE!!!!
HEAD LICE ALERT
Dear Parent:
Date:
1.
Check everyone’s hair in your household.
2.
If your child has head lice, you should do ONE of the following:
a.
If your insurance covers medicines, or you have Medi-Cal, call your doctor for a
prescription for shampoo.
b.
Check your local drug store for lice shampoos.
3.
All members of the household should be treated using the special shampoo you obtained from any
of the above. PLEASE FOLLOW THE DIRECTIONS ON THE LABEL CAREFULLY.
4.
Remove all nits (eggs) with a nit comb. It is very important that all nits be removed to help
prevent reinfestations.
5.
Repeat treatment in 7-10 days to kill any undetected nits which may have hatched after the first
treatment.
6.
Wash all personal clothing, bedding, combs and brushes in hot water. Nonwashable items can be
dry cleaned or placed in plastic bags for 2 weeks.
7.
Vacuum all upholstered furniture, mattresses, and carpets. These could also be sprayed with
special insecticides. Please consult your pharmacist.
Students who were excluded will be readmitted only after treatment and after all nits (eggs) are removed.
IT IS STRONGLY RECOMMENDED THAT YOU ACCOMPANY YOUR CHILD TO THE SCHOOL
HEALTH OFFICE FOR READMISSION.
If you have any questions, please call your child’s school office personnel.
Un piojo hembra
Padres informados y preocupados
30 días
equivale a
100 piojitos
control efectivo de piojos
equivale a
¡NINGÚN PIOJITO!
ALERTA DE PIOJOS
Estimado padre:
1.
Revise el cabello de todos los que estén en su hogar.
2.
Si su hijo tiene piojos, debe hacer UNO de los siguientes:
Fecha:
a.
Si su seguro médico cubre medicamentos, o tiene Medi-Cal, comuníquese con su doctor
para una receta para un champú.
b.
Vaya a su farmacia local para conseguir champú para los piojos.
3.
Todos los miembros de su hogar deben recibir tratamiento usando el champú especial que
consiguió de los antedichos. FAVOR DE SEGUIR CUIDADOSAMENTE EL MODO DE
EMPLEO DE LA ETIQUETA.
4.
Remueva todas las liendres (huevos) con el peine para liendres. Es muy importante que todas las
liendres sean removidas para ayudar a prevenir nuevas infestaciones.
5.
Repita el tratamiento en 7-10 días para matar cualesquiera liendres no detectadas que pudieron
haberse eclosionado después del primer tratamiento.
6.
Lave toda la ropa, ropa de cama, peines y cepillos personales en agua caliente. Los artículos que no
se puedan lavar pueden mandarse a la tintorería o ser puestos en bolsas de plástico por 2 semanas.
7.
Aspire todo los muebles tapizados, colchones y alfombras. Estos también pueden rociarse con
insecticidas especiales. Por favor consulte con su farmacéutico.
Los alumnos que fueron excluidos serán readmitidos solamente después de haber recibido el tratamiento y
después que las liendres (huevos) sean removidas.
SE RECOMIENDA FUERTEMENTE QUE USTED ACOMPAÑE A SU HIJO A LA OFICINA DE
SALUD DE LA ESCUELA PARA READMISIÓN.
Si tiene cualquier pregunta, por favor llame al personal de la oficina escolar de su hijo.
MEDICATIONS AT SCHOOL
California Educational Code 49423 authorizes the school nurse or other designated personnel to assist students who are
required to have medication during the school day when there is a written request from the physician and the parent.
The Health Aide must be sure that the following steps are taken:
Request: It is the parent’s responsibility to obtain a “Physician’s request for Medication”
showing:
a. Name of student
b. Name, strength, dosage and time for medicine
c. Directions for giving medication
d. Name and signature of doctor (Nurse practitioner or PA)
e. Signature of parent
Container: The medication must be in the original pharmacy container. Parents may need to have the pharmacist prepare a second
container for a supply at home.
Medication Record Card: The Health Aide will complete a Medication Record Card (HE-13). Be sure to get the signature of one or two
other staff people who have been authorized to give medication in your absence.
Administration: Great care must be given when assisting students taking medication.
Have the student give you his/her name every time. They will soon learn that this is part of the procedure.
Read label very carefully-three times taking it out of cabinet, checking the order, and when giving it)
Check medication record card to be sure that it has not been given by someone else and that you have the right medication
Tip pill/s into the cap of container
Observe the student taking the medication
Record: Record medication immediately with the time and your initials.
Store: Medications must be stored in a locked drawer or cabinet, unless refrigerator is needed.
List of Students: Keep an up to date list of students available for yourself as well as anyone who gives medication when you are not
there.
No shows: Students sometimes forget to come in for their medication. (Students taking Ritalin or similar medications are very prone to
this. That is why they need it) Some Health Aides find it helpful to prepare a daily check off list. Others make small “med cards” that they
keep in order of time to be given and turn over or set aside after they are given. Get in the habit of checking these methods several times
during lunch hours. If a student does not come in, call the classroom.
Cancellation of request: A parent may request that you stop a medication. Ask them to put this request in writing, make a note of any
phone requests.
Refusal: If a student refuses to take medication, notify parents immediately. Also notify teacher, principal or school nurse as appropriate.
Disposal: Check with the school nurse regarding disposal of medications and sharp containers
STUDENTS
Procedure No. 5149a
ADMINISTERING MEDICATION TO STUDENTS
California Education Code (C.E.C.) 49423 authorizes the school nurse or other designated
personnel to assist students who are required to have medication during the school day.
Before a designated employee administers any prescribed medication, the District must have
received the following:
1.
A written statement from the student’s physician detailing the method, amount, and
time schedules by which the medication is to be given. (Note: A new order is required each
school year or when the dosage changes.)
2.
A written statement from the parent or guardian of the pupil indicating the desire to
have school personnel assist the pupil in taking the prescribed medication.
3.
The medication in the original pharmacy container. The label shall contain the name
of the prescribing physician, name of the student, name of the medication, dosage,
frequency of administration, and the expiration date.
All medications must be delivered to the school by the parent, guardian, or authorized
adult representative. The designated employee will count the pills in the presence of the
parent/guardian/authorized adult for all controlled substances. The number of pills
received will be recorded on the Medication Record card (HE-13) along with the date and
employee’s signature. The employee will count the medication weekly and record the result
on the Medication Record Card.
The medication shall be stored in a locked drawer or cabinet unless refrigeration is
required. There shall be no more than two keys for the medication cabinet. The principal
shall keep one key and the other be in the possession of the health aide or other
designated employee at all times. The cabinet or drawer will be re-keyed within 24 hours
if it is discovered any medication or one of the keys are missing. In such case, the
principal or designee will complete a student incident report, call the school nurse, and
report the incident to School Police immediately.
The health aide or other designated employee administering medication must attend an annual
training conducted by a credentialed school nurse, public health nurse, or physician. If
an employee is hired after the annual training, a credentialed school nurse, or physician
will conduct the training for the new employee at the site. No employee shall administer
medication without first being properly trained. The health aide or other designated
employee is responsible for administration of the medication as prescribed. Medication
must be administered within 30 minutes of the specified time. Compliance will be monitored
by the school nurse and shared with the site principal quarterly.
Students may self administer emergency medications such as inhalers, epi-pens, or insulin
if the following conditions have been met: (1) a Physician’s Request for Medication form
signed by the physician and parent is on file; (2) the student has demonstrated he/she is
physically, mentally, and behaviorally capable of administering the medication safely. The
school nurse will assess the student and provide supervision as needed. A Medication
Record card will be completed by students who self administer their own medication in order
to have a record that the medications is being taken in case of emergency or question
regarding use.
STUDENTS
Procedure No. 5149a
The health aide or other designated employee will document the administration of all
medications on the Medication Record card. Documentation will also include absences,
refusals, off track, or other reasons for a medication not being administered. A
confidential list of students receiving medications during school hours is to be
maintained.
The parent or guardian will be asked to pick up medications at the end of the school year
or if the medication changes during the school year. The number of pills returned is to be
recorded on the Medication Record Card including the date and signature of the employee
returning the medication. Medications not claimed at the end of the school year are to be
discarded as recommended by the local health officer and appropriate OSHA guidelines. Any
medication not picked up by the parent is to be taken to the Health Services office for
appropriate disposal. Such action is to be noted on the Mediation Record Card. The
Physician’s Request for Medication and Medication Record card are to be maintained in the
student’s cum folder.
Superintendent
California Education Code 49423 and SBCUSD Board Policy and Administrative Regulation 5141.21 authorizes
the School Nurse or other trained designated school personnel to assist your child in taking medication at school
when certain requirements are met. The requirements that must be met each school year are:




Physician’s Request for Medication form signed by the physician and parent which also has the name of
the student, medication, dose, time, route and physician’s contact information.
The medication must be brought to school by a parent or guardian in the original container with a
prescription label.
The same process must be followed for over-the-counter medications to be taken at school.
Students must demonstrate the physical, mental and behavioral capability to safely self-administer
medication.
The parent or guardian must pick-up unused medication at the end of the school year. Any medication not
picked up within two weeks of school closure will be discarded based on the recommendations of the local health
officer and OSHA guidelines for disposal of hazardous waste.
Visit the Health Services section of our District website at http://sbcusd.com for more information or contact
your school nurse for assistance.
Sincerely,
1535 W. Highland Avenue
San Bernardino, California 92411
Phone (909) 880-6839
[email protected]
Superintendent
Estimado padre/tutor legal:
El 49423 del Código de Educación de California y el Reglamento y la Regulación Administrativa 5141.21 de la Mesa
Directiva del Distrito Escolar Unificado de la Ciudad de San Bernardino autorizan al enfermero escolar u otro
personal escolar capacitado designado a ayudarle a su hijo tomar medicamento en la escuela cuando se cumplen
ciertos requisitos. Los requisitos que deben cumplirse cada año escolar son:




El médico y el padre han de firmar el formulario Solicitud del Médico para el Medicamento, el cual también
tendrá el nombre del alumno, el medicamento, la dosis, la hora, la vía de administración y la información de
contacto del médico.
El medicamento debe traerse a la escuela por el padre o tutor legal en su envase original con la etiqueta de la
receta.
El mismo proceso debe seguirse para el medicamento sin receta que ha de tomarse en la escuela.
Los alumnos deben demostrar la capacidad física, mental y conductual para autoadministrarse el
medicamento prudentemente.
El padre o tutor legal deben recoger el medicamento que no se tomó al final del año escolar. Cualquier
medicamento que no se recoja dentro de dos semanas después de la terminación de clases será desechado sobre la base
de las recomendaciones del funcionario local de sanidad y las pautas de la Administración de Seguridad y Salud
Ocupacional (OSHA, por sus siglas en inglés) para la eliminación de desechos peligrosos.
Visite nuestra sección de Servicios de Salud en nuestro sitio web del distrito al http://sbcusd.com para mayor
información o para más ayuda comuníquese con la enfermera escolar.
Atentamente,
Coordinadora, Servicios de Salud
Distrito Escolar Unificado de la Ciudad de San Bernardino
1535 W. Highland Avenue
San Bernardino, California 92411
Núm. telefónico (909) 880-6839
[email protected]
WHEN GIVING MEDICATION
RIGHT
STUDENT
RIGHT
TIME
RIGHT
MEDICINE
RIGHT
DOSE
RIGHT
ROUTE
RIGHT RECORD
MEDICAL ABBREVIATIONS
P.O.
Orally
b.i.d.
Twice a day/24 hours
t.i.d.
Three times a day/24 hours
q.i.d.
Four times a day/24 hours
qd
Once a day
5cc
One teaspoon/ must have accurate measurement
gtt.
Drop
p.r.n.
As needed
q.h.
Every hour
o.d.
Right eye
o.s.
Left eye
o.u.
Both eyes
ac
Before meals
pc
After meals
i
ii
One
Two
Hx
History of
MIS #:____________
Health Services
PHYSICIAN’S RECOMMENDATIONS FOR MEDICATION
__________________________
Pupil’s Last Name
_____________
First Name
____
M.I.
_____
Age
___________
Birthdate
______________________ ______
School
Grade
The law allows school nurses or other designated personnel to assist the pupil in taking prescribed medications if specified written
statements from physicians and parent or guardian of pupil are obtained by the district.
Ed. Code 49423.
I hereby give my permission for school personnel to give the medication(s) listed below as directed. I also give the school nurse
permission to contact the physician regarding the child’s reaction to the medication or if there is a change in the child’s health.
________________________________
Parent or Guardian Signature
___________________________________
Address
__________________
Telephone
_____________
Date
RECOMMENDATIONS SHOULD BE COMPLETED BY PHYSICIAN ONLY
IMPORTANT: All medications will automatically be discontinued on June 30. New orders are required each school year.
(Circle One)
#1 ___________________
Medication
_________
Strength
________
Dose
___________
Route
Routine___________________
Time(s) to be given (AT SCHOOL)
_______________
PRN__________________________
Stop Date
Frequency
If PRN, give for:
Side Effects, if any:____________________________________________________________________________________________________
____________________________________________________________________________________________________________________
#2
Medication
Strength
Dose
Route
(Circle One)
Routine ___________________________
Time(s) to be given (AT SCHOOL
PRN______________________________
________________
Stop Date
Frequency
If PRN, give for: ____________________________________________________________________________________________________
Side Effects, if
any:__________________________________________________________________________________________________
__________________________________________________________________________________________________________________
#3_______________________ ____________ _________
Medication
Strength
Dose
(Circle One)
____________ Routine__________________________
Route
Time(s) to be given (AT SCHOOL)
______________
Stop Date
PRN _____________________________
Frequency
If PRN, give for:____________________________________________________________________________________________________
Side Effects, if any: _________________________________________________________________________________________________
___________________________________________________________________________________________________________________
________________________________________
Physician’s Name (Printed)
HE-24 (6-98)
______________________________ __________________________________ ___________
Signature
Address
Date
Telephone
FAX #__________________________
SUGGESTIONS FOR SCHOOL PROCEDURES
The procedures covering medication brought to school to be taken by pupils according to the provisions listed on the
other side of this form will be expedited if the following procedures are used:
1.
Only medication prescribed by the pupil’s physician as being necessary to be
taken by the pupil in the manner listed on this form should be brought to school.
2.
Such medication should be taken by the pupil in accordance with instructions
from the physician listed on this form.
3.
Medication brought to school to be given to the pupil according to the provisions
listed on this form should be in containers which are clearly marked with the name
of the pupil; the name of the prescribing physician; an identification number or
name of the medication; the druggist who dispensed the medication or the
manufacturer; and the amount of medication to be taken at specified times or in
specific situations.
4.
All medication should be kept in a secure place. Any special instructions for storage or
security measures of any medication should be written by the physician
and given to school personnel so that such instructions can be followed.
Epinephrine/EpiPen
WHY?
Anaphylaxis is a sudden, severe allergic response that produces breathing difficulties, collapse and possible death.
Can be caused by insect stings, medications like penicillin or a reaction to foods like peanuts (nuts), shellfish, eggs,
fish, beef, pork, soy, potato or wheat products.
WHAT WILL I SEE?
Student may initially have:
Tingling lips and mouth
Flushing of face or body
Itchy eyes, nose or face
Vomiting
Hives
Diarrhea
Wheezing
Symptoms may rapidly progress to:
Weakness and dizziness
Throat swelling
Inability to breathe
Loss of consciousness
HOW CAN I HELP?
Call 911, parents and school nurse.
Get the student’s EpiPen kit. Check the expiration date.
Form a fist around the auto-injector with the black tip facing down.
Pull off the gray cap.
Place the black tip against the student’s outer thigh.
With a quick motion, push the auto-injector firmly against the thigh,
hold in place and count to 10.
Remove EpiPen and massage area for 10 seconds.
Epinephrine
How to administer
1. Pull off blue safety cap.
2. Place the orange tip on the outer thigh.
3. Press the auto-injector firmly against the
thigh so it clicks. Hold for 10 seconds
Glucagon
How to administer
1. Check expiration date.
2. Take off safety cap on syringe and vial of dry
powder, inject liquid into dry powder and mix.
3. Draw out liquid into syringe and inject into muscle
of arm, thigh or buttocks.
4. Turn student on side.
How do I take my
inhaler?

Shake the canister

Breath out to empty lungs

2 finger distance or spacer

Press down and breathe in

Hold breath for 10 seconds

Wait 1-2 minutes

Take second puff
CHILD WELFARE FUND
The Child Welfare Fund is a unique fund and organization supported by all employees of the
San Bernardino City Unified School District. It is a private fund - not District monies.
Its primary purpose is to meet the needs of students so that they can better attend and be successful in school.
If a parent request or indicates a need for assistance in obtaining glasses, prescriptions, etc., the Health Aide
should:
1. Complete the Social History Card (HE-9) while talking to the parent. The
Health Aide should never promise assistance - simply offer to collect necessary information and
relay the need to the school nurse.
2. Notify the School Nurse as soon as possible. She will then investigate further and complete the
Child Welfare Fund Referral Form (HE-49) which the parent will take to the care provider to
authorize service.
3. Provide transportation or other assistance as needed.
4. Contact the school principal for funds for small items. The Principal may send an IOC to the CWF
treasure to obtain funds.
5. Health Aides are always welcome to attend and participate in meetings of the
Child Welfare Board. This is the best way to be knowledgeable and helpful.
Please contact your school nurse for forms
Form: Child Welfare Form
Number: HE-9
Order from: Health Services
See following page for referral form (make copies as needed
SAN BERNARDINO CITY UNIFIED SCHOOL DISTRICT HEALTH SERVICES DEPARTMENT
CHILD WELFARE FUND REFERRAL
DATE:_____________
NAME OF STUDENT _________________________________ MIS #: _____________________
SCHOOL _________________________________________ BIRTH DATE: __________________
Is referred to:
For:
□
□
Date/Appointment:
REFRACTION
GLASSES with basic frames
□
□
Nurse’s Concern:
□
□
□
FRAME ONLY
LENSES ONLY
MEDICAL CARE
PRESCRIPTION
CO-PAYMENT: $____________
880-6839 or ________________
Telephone
Signature of School Nurse:
PROVIDER: VOID AFTER 90 DAYS
CHILD WELFARE FUND ONLY:
THIS REFERRAL IS FOR ONE VISIT/SERVICE ONLY.
Service must be billed to CHILD WELFARE FUND.
Date: _______________________________
Cost: _______________________________
Co-Pay:_____________________________
Bal. to CWF: ________________________
To Treas.: ___________________________
Paid: _______________________________
Check #: ____________________________
Mail to:
HEALTH SERVICES – CHILD WELFARE
1535 W. Highland Avenue, Room 11
CHILD WELFARE FUND USE DISCLAIMER
PARENT SIGNATURE REQUIRED
The Child Welfare Fund was established by the employees of San Bernardino City Unified School District to
provide one-time or temporary assistance to students attending schools within our district. The program was never
meant to be used as an ongoing resource to cover the cost for an individual student’s basic or health care needs, nor
was it to be used on an annual basis.
As the parent of ___________________________________________________ I understand that use of the Child
Welfare Fund is for one time only. I will research other resources to take care of all future basic or health care
needs my child may have.
Signature __________________________________________
Date________________________________
DEPARTAMENTO DE SERVICIOS DE SALUD DEL
REFERIDO PARA EL CHILD WELFARE FUND (FONDO DEL BIENESTAR DE NIÑOS)
FECHA:_________
NOMBRE DEL ALUMNO ______________________________ MIS #: ________________
ESCUELA ___________________________________________FECHA DE NACIMIENTO: __________
Está referido a:
Fecha/cita:
Para:
□
□
REFRACCIÓN
ANTEOJOS con monturas básicas
□
□
Inquietud del enfermero:
□
□
□
MONTURAS SOLAMENTE
LENTES SOLAMENTE
ATENCIÓN MÉDICA
RECETA
COPAGO: $____________
880-6839 ó ________________
Núm. telefónico
Firma del enfermero escolar:
PROVEEDOR: NULO DESPUÉS DE 90 DÍAS
ESTE REFERIDO ES SOLAMENTE PARA UNA
VISITA/UN SERVICIO. Servicio debe cobrarse a CHILD
WELFARE FUND.
Enviase a: HEALTH SERVICES – CHILD WELFARE
1535 W. Highland Avenue, Room 11
SÓLO PARA EL USO DE CHILD
WELFARE FUND:
Date: _______________________________
Cost: _______________________________
Co-Pay:_____________________________
Bal. to CWF: ________________________
To Treas.: ___________________________
Paid: _______________________________
Check #: ____________________________
DESCARGO DE RESPONSABILIDAD PARA EL USO DEL CHILD WELFARE FUND
SE REQUIERE LA FIRMA DEL PADRE
El Child Welfare Fund fue establecido por los empleados del Distrito Escolar Unificado de la Ciudad de San
Bernardino para suministrar ayuda única o temporal a los alumnos asistiendo a escuelas dentro de nuestro
Distrito. El programa nunca tenía la intención de ser un recurso continuo para cubrir los gastos de las
necesidades básicas o de atención médica de un alumno en particular, ni de ser usado anualmente.
Como padre de___________________________________________________ entiendo que el uso del Child Welfare
Fund es para uso único solamente. Buscare otros recursos para atender las futuras necesidades básicas y de
atención médica que mi hijo quizá tenga.
Firma __________________________________________
fecha________________________________
SOCIOLOGICAL SERVICES
Sociological Services is an intricate part of a support system designed to enhance the school sites ability to support
the family. The focus of our goals is to empower our families to take responsibility for their lives. Sociological
Services assist families of all school aged children.
Services are provided according to need, but may include emergencies such as food, clothing, counseling, utility
payments and transportation.
1. Complete a SOCIOLOGICAL REFERRAL for services (GA-26)
2. Hand deliver or bring the completed form to the Family Resource Center
(The family will be contacted to attend classes prior to obtaining assistance)
For Clothing:
1. Once the family completes the class, you will be notified. At that time you can
met them) at DD’s Discount store to purchase clothing.
Do not take the student. Do not give the parent the voucher.
take the parent (or
2. After shopping, remove all tags, and bring the receipt back to the Family Resource Center.
To obtain forms, call the Family Resource Center or Sociological Services
Number: GA-26
OPERATION SCHOOL BELL
Project of Assistance League®
of San Bernardino
There are 4 forms that need to be completed for each child:
Please note, this service does not assist High School Students
1. The Operation School Bell Referral Form (E-64) – One per child
2. A Sociological Services Referral Form (GA-26) to verify eligibility
NOTE: Family CANNOT receive any public assistance (AFDC, TANF,
Food stamps, Medi-cal, SSI, or SSA).
3. Release for publicity form for the Assistance League of San Bernardino.
4. Field Trip/Excursion Waiver (BU-76), signed by parent/guardian (available at each school
location). Keep on file for your records.
Please return the completed E-64, GA-26 and the release for publicity forms to the Family Resource Center.
A school staff employee must transport student to and from Wal-Mart. Parents cannot transport their children.
Members of the Assistance League of San Bernardino will take the students shopping for their clothes at WalMart.
HEARING
Hearing screening is done at the school by the School Nurse or Audiometrist for
grades K, 2,5,8,10 and all new students.
Procedure:
1. School Nurses/Audiometrists arrange schedule of grades to be screened and notify each
school. Health Aides should notify teachers when screening is scheduled for their class.
2. Health Aides should keep a list of students who have been referred.
3. The Audiometrist will document in the Student Information System indicating if the student
passed or was referred
THRESHOLD TESTING
This is done by the School Nurse/Audiometrist for any child who fails screening or has a known or suspected
hearing loss.
1. Threshold testing is performed on the day a student fails a screening
2. Second threshold is performed from 2-6 weeks after the first test
3. If second threshold is failed, an audiogram and Referral for Medical Evaluation form is sent
to parent/guardian
4. Student may also be referred to doctor for evidence of pathology, such as infections of the
outer ear, chronic drainage, or chronic earache
SCOLIOSIS SCREENING
Scoliosis screening is a special program of Health Services for seventh grade girls and eighth grade
boys. Health Services will arrange all screening, evaluation, referrals, and follow-up.
Health Aide responsibilities:
1. Make 2 copies of attendance roster for each P.E. class
a. On one set, names of 7th grade girls
b. On the other set, names of the 8th grade boys
2. Make two copies of bell schedule
3. Record results of each student’s screening into the Student Information System
VISION SCREENING
California Education Code (C.E.C.) 49452 mandates the vision screening of all students at certain intervals as well as all
new students and those referred.
The School Nurse will:
1. Screen visual acuity of students:
nd
th
th
a. In Kindergarten, 2 , 5 and 7 grades.
b. Who are new.
c. Referred by school staff or parents.
st
2. Do color vision of Kindergarten or 1 grade boys as well as any student who
have not been previously tested.
3. Refer:
a. Kindergarten students with less then 20/40 20/40 vision *.
b. Grade 1 through 12 students with less than 20/30 20/30 vision.
c. Students with significant symptoms.
d. Boys who fail color vision screening. (There is no correction, but parents should be informed.)
4. Assist parents in obtaining necessary care by referral to private or MediCal
sources or use of Child Welfare Funds if necessary.
1.
2.
3.
4.
Notify teachers of scheduled screening.
Get a copy of current attendance roster (with MIS numbers).
Collect returned vision notices and notify school nurse of requests for assistance.
Assist parents with transportation to appointments if necessary.
* The first number relates to the distance from the eye chart that the person was screened. The second number indicates the distance
from the eye chart that most people could see that line. (School vision charts are calibrated for 10 foot use.)
20/20 means that a person screened 20 feet away from the eye chart is able to see what most people can see from 20 feet, 20/40
means that the person can see what most people would be able to see from 40 feet away, etc.
Vision Referral Form:
HE-34 (English/Spanish)
See following page
Health Services
1535 W. Highland Ave.
REFERRAL FOR VISION AND EYE EVALUATION
Name
MIS/Student No.
Date
School
Grade
Tr.
Rm.
Recent vision screening showed that your child should have a complete eye evaluation by an eye doctor
(optometrist or ophthalmologist). Eye problems or poor vision may affect your child’s ability to learn.
It is important that you make an appointment as soon as possible. Please have the eye doctor fill out the section
below and return it to the school nurse.
School Nurse’s
concern:_________________________________________________________________________________
If you have any questions, do not have medical insurance or need financial help to see an eye doctor, please call 880-6839.
_______________________________
School Nurse
REPORT OF COMPREHENSIVE EYE EXAMINATION
Date of Examination
Unaided Visual Acuities: O.D. (Right eye)
Refraction:
O.S. (Left eye)
O.D.
O.S.
Diagnosis:
Glasses:
No
Yes
To be worn:
Preferential seating:
No
Yes ____
Comments:
Doctor’s Name Printed:
Address:
Signature
Date
Phone:
Thank you for your cooperation.
Note to Examiner
Please mail completed form to:
HE-34 (5-98)
Health Services
1535 West Highland Ave.
Distrito Escolar Unificado de la Ciudad de San Bernardino
Departamento de Servicios de salud (Health Services)
1535 W. Highland Ave.
REFERENCIA PARA LA EVALUACIÓN DE LA VISTA Y LOS OJOS
Nombre
Núm. de identificación
Fecha
Escuela
Grado
Sesión
Salón
Estimados padres/tutores legales:
Un examen de la vista, mostró recientemente que su hijo/a necesita que un doctor de la vista (optometrista u
oftalmólogo) le realice un examen completo de la vista. Los problemas de la vista o de los ojos pueden afectarle a
su hijo/a la habilidad para aprender.
Es importante que usted haga una cita lo antes posible. Por favor solicítele al doctor que llene la sección de abajo y
la devuelva al enfermero de la escuela.
Preocupación del enfermero escolar:
___________________________________________________________________________
Si usted tiene alguna pregunta, no tiene seguro médico o necesita ayuda financiera para visitar a un doctor de la
vista, por favor llame al 880-6839.
_______________________________________
Enfermero escolar
REPORT OF COMPREHENSIVE EYE EXAMINATION
Date of Examination
Unaided Visual Acuities:O.D. (Right eye)
Refraction:
O.S. (Left eye)
O.D.
O.S.
Diagnosis:
Glasses:
No
Yes
Preferential seating:
No
Yes____
To be worn:
Comments:
Doctor’s Name Printed:
Signature
Address:
Date
Phone:
Thank you for your cooperation.
Note to Examiner
Please mail completed form to:
HE-34 (5-98)
Health Services
1535 West Highland Ave.
SCHOOL NURSE
The School Nurse serves as “the primary health professional within the school community”. *The
School Nurse role is to help meet the needs of children in relation to their academic needs.
The School Nurse does this through:
1. Health appraisals including, but not limited to:
a. Vision and hearing screening
b. Dental screening
c. Scoliosis screening
d. CHDP clinics and other physical assessments
2. Assistance with and monitoring of existing health conditions through:
a. Specialized Physical Health Care procedures (Spec's)
b. Monitoring medications at school
3. Follow up and remediation of identified health problems by means of:
a. Personal, phone or letter contacts
b. Case management
4. Communicable disease control through:
a. Identification and isolation of communicable diseases and infestations
b. Evaluation of immunization records
c. Immunization and TB skin test clinics
5. Assessment of growth, development and nutrition.
6. Emergency response on-site or telephone response and advice.
7. Special Education:
a. Assessment of student
b. Health and Development history
c. IEP team member
8. Home visits providing liason between home and school.
9. Referral to community resources and agencies such as:
a. Local physicians, clinics, dentists, etc.
b. Local agencies
10. Assistance in obtaining care through resources such as:
a. Medi-Cal
b. Healthy Families
c. Child Welfare Fund
School Nurse cont.
1
11. Involvement in and remediating attendance through SART and SARB meeting.
12. Record keeping.
13. Evaluation and support of environmental health regarding:
a. Health Office
b. Biohazardous materials
14. Inservice of paraprofessionals and health staff.
15. Health Education regarding:
a. 6th grade HIV and Hepatitis classes,
b. 9th Grade sex education,
c. Health education classes as appropriate
16. Liason between medical community, parents, school, etc.
17. Participation in school and community committees for:
a. Health resources,
b. Health Education planning,
c. School Nurse education
18. Membership in professional organizations such as:
a. California School Nurses Organization (CSNO)
b. National Association of School Nurses (NASN)
c. National Association of Pediatric Nurse Associates/Practitioners (NAPNAP)
d. American and California Nurses Association (ANA and CNA )
e. Related local organizations
*Mission statement of the California School Nurses Organization 1998-99
2
SPECIAL SCHOOLS AND PROGRAMS
Special Education provides a full range of special programs and services for children and youth between the
ages of birth and twenty-two years.
An Individualized Education Program (IEP) Team, including the parent/guardian/caregiver, persons who have
assessed the individual, teacher and administrator meet to determine if an individual is eligible and in need of a
special education program or service(s). A parent/guardian/caregiver may contact the local school principal or
the District Special Education Office.
Students are served in a variety of settings determined by individual need. The regular classroom with
modifications and adaptations is usually the most appropriate. A specialist may consult with the staff to assist
in meeting these specialized needs.
Resource Specialist Program (RSP)
A resource teacher provides services for teachers and students on site. The
Resource program may serve students in the classroom (collaboration), individually or in small groups.
Special Day Classes (SDC)
Special Day Classes are provided for individuals with exceptional needs who require special education instruction
for the majority of the school day. Special Day classes are provided for individuals who have a variety of
handicapping conditions, including learning disabilities, deafness/hard of hearing, severe disorders of
language/aphasia, orthopedic impairments, retardation, multiple handicaps, visually impaired and severe
emotional disturbances.
Designated Instruction and Services (DIS)
A variety of services are provided to individuals with exceptional needs under the heading of Designated Instruction and
Services including, but not limited to:
Adapted Physical Education (APE): Adapted physical education is for individuals with exceptional needs who
require developmental or corrective instruction and who are not able to participate in the activities of the general
physical educational program, modified general physical program, or in a specially designed physical education
program in a special class.
Health and Nursing Services: Health and nursing services are provided to individuals with exceptional needs,
when necessary, in order for the individual to benefit from his/her special educational program in the least
restrictive environment.
3
SPECIAL SCHOOLS AND PROGRAMS cont.
Speech and Language Services: Speech and language therapists provide instruction and service for individuals
with disorders of language, speech, and /or hearing.
Physical and Occupational Therapy: Physical and occupational therapy are provided for individuals who meet
eligibility guidelines of California Childrens Services (CCS)
Visually Impaired: Students identified as visually impaired may receive instruction with modified materials,
training in traveling within the community, and/or Braille. Classroom teachers may be assisted in using special
materials and strategies.
Psychological Services
A school psychologist is assigned to each school in the district. Psychologists assist in identifying students with
special needs. They assess and evaluate students referred to them and interpret findings to school personnel
and parents. They also serve as consultants to parents and school staff in educational planning, management
and referrals to appropriate agencies for services not available in the schools.
Services for Infants
Services are provided for infants from birth to age three who have a disabling medical condition or congenital
syndrome requiring special education services, and for infants who have a moderate delay in two of the following
areas or a severe delay in one area: motor development, language development, social development, and/or
cognitive/intellectual development.
Services for Pre-School Pupils
Pre-school pupils between the ages of three and five years with substantial handicapping conditions requiring
intensive special education services are served in Special Day Classes and Special Schools. Pre-school pupils
who are not substantially handicapped but who need and are eligible for special education services can receive
services from a Speech and Language Specialist and/or a Resource Specialist at the closest elementary school,
or when appropriate, pre-school program in which the pupil is enrolled.
4

Health Aide Procedure Manual - San Bernardino City Schools

Transcription

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